Provider Demographics
NPI:1497984660
Name:GEBREMEDIHN, MUSSIE (MD)
Entity Type:Individual
Prefix:
First Name:MUSSIE
Middle Name:
Last Name:GEBREMEDIHN
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 1:1468 MONTREAL RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6901
Mailing Address - Country:US
Mailing Address - Phone:770-638-1400
Mailing Address - Fax:770-638-1411
Practice Address - Street 1:1468 MONTREAL RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6901
Practice Address - Country:US
Practice Address - Phone:770-638-1400
Practice Address - Fax:770-638-1411
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2016-0240207RC0000X
GA86427207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM69104778Medicaid
NM69104778Medicaid