Provider Demographics
NPI:1164775433
Name:GEBRESELASIE, BERHANE ADHANOM (MD)
Entity Type:Individual
Prefix:
First Name:BERHANE
Middle Name:ADHANOM
Last Name:GEBRESELASIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 WAYNE AVE APT 5G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2518
Mailing Address - Country:US
Mailing Address - Phone:917-515-2344
Mailing Address - Fax:
Practice Address - Street 1:1001 S GEORGE ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-3676
Practice Address - Country:US
Practice Address - Phone:717-851-4005
Practice Address - Fax:717-812-2495
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD455139207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103043499Medicaid
PAP01572186Medicare PIN
PA103043499Medicaid