Provider Demographics
NPI:1225098783
Name:FESSEHA, TEWODROS (MD)
Entity Type:Individual
Prefix:
First Name:TEWODROS
Middle Name:
Last Name:FESSEHA
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 1:22255 GREENFIELD RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3710
Mailing Address - Country:US
Mailing Address - Phone:248-552-8525
Mailing Address - Fax:248-552-1134
Practice Address - Street 1:22255 GREENFIELD RD
Practice Address - Street 2:SUITE 240
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3710
Practice Address - Country:US
Practice Address - Phone:248-552-8525
Practice Address - Fax:248-552-1134
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301056254208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI34063119028OtherBCBSM
MI413271410Medicaid
MI413271410Medicaid
MIN98330001Medicare ID - Type Unspecified