Provider Demographics
NPI:1376094615
Name:ABRAHAM INFECTIOUS DISEASE ASSOCIATES 2 LLC
Entity Type:Organization
Organization Name:ABRAHAM INFECTIOUS DISEASE ASSOCIATES 2 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GIZATCHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:KETSELA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850918-240-5850
Mailing Address - Street 1:2910 KERRY FOREST PKWY # D4-369
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-6892
Mailing Address - Country:US
Mailing Address - Phone:850-329-2872
Mailing Address - Fax:850-329-2882
Practice Address - Street 1:2927 KERRY FOREST PKWY
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-7815
Practice Address - Country:US
Practice Address - Phone:850-329-2872
Practice Address - Fax:850-329-2882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99953207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty