Provider Demographics
NPI:1275728289
Name:MENGISTU YEMANE MD PLLC
Entity Type:Organization
Organization Name:MENGISTU YEMANE MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MENGISTU
Authorized Official - Middle Name:
Authorized Official - Last Name:YEMANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-451-8644
Mailing Address - Street 1:30 TOWER CIR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3476
Mailing Address - Country:US
Mailing Address - Phone:606-451-8644
Mailing Address - Fax:606-451-9644
Practice Address - Street 1:30 TOWER CIR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3476
Practice Address - Country:US
Practice Address - Phone:606-451-8644
Practice Address - Fax:606-451-9644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38234207R00000X
KY4821P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYDH2005OtherRR MDC
KY64066574Medicaid
KYDH2005OtherRR MDC
KY1937001Medicare PIN