Provider Demographics
NPI:1285628768
Name:TILAHUN, ERMIAS (MD)
Entity Type:Individual
Prefix:
First Name:ERMIAS
Middle Name:
Last Name:TILAHUN
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 1:5015 N PAULINA ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2756
Mailing Address - Country:US
Mailing Address - Phone:773-907-3550
Mailing Address - Fax:773-907-3566
Practice Address - Street 1:5015 N PAULINA ST STE 101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2756
Practice Address - Country:US
Practice Address - Phone:773-907-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-094888207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-094888-1Medicaid
ILG55334Medicare UPIN
ILL59285/357801Medicare ID - Type Unspecified