Provider Demographics
NPI:1376545947
Name:BEKELE, TAMRAT (MD)
Entity Type:Individual
Prefix:DR
First Name:TAMRAT
Middle Name:
Last Name:BEKELE
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 1:165 FALL BROOK ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-0000
Mailing Address - Country:US
Mailing Address - Phone:570-282-3151
Mailing Address - Fax:570-282-3231
Practice Address - Street 1:165 FALL BROOK ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-0000
Practice Address - Country:US
Practice Address - Phone:570-282-3151
Practice Address - Fax:570-282-3231
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD065698L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001781629Medicaid
PAH05119Medicare UPIN
PA001781629Medicaid