Provider Demographics
NPI:1235122912
Name:GEBREMARIAM, MOGES (MD)
Entity Type:Individual
Prefix:
First Name:MOGES
Middle Name:
Last Name:GEBREMARIAM
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 1:4660 WILKENS AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-4848
Mailing Address - Country:US
Mailing Address - Phone:410-242-5520
Mailing Address - Fax:410-242-5627
Practice Address - Street 1:4660 WILKENS AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-4848
Practice Address - Country:US
Practice Address - Phone:410-242-5520
Practice Address - Fax:410-242-5627
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD18327207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B69479Medicare UPIN
MD3473Medicare ID - Type Unspecified