Provider Demographics
NPI:1235239039
Name:KIDANE, MEHARI CAHSAI (S)
Entity Type:Individual
Prefix:MR
First Name:MEHARI
Middle Name:CAHSAI
Last Name:KIDANE
Suffix:
Gender:M
Credentials:S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1829 E FAIRMOUNT AVE
Mailing Address - Street 2:1829 E,FAIRMOUNT AVE
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5903
Mailing Address - Country:US
Mailing Address - Phone:602-577-4419
Mailing Address - Fax:602-274-0452
Practice Address - Street 1:1829 E FAIRMOUNT AVE
Practice Address - Street 2:1829 E,FAIRMOUNT AVE
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5903
Practice Address - Country:US
Practice Address - Phone:602-577-4419
Practice Address - Fax:602-274-0452
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZB10067102343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)