Provider Demographics
NPI:1619288339
Name:KIDANU BIRHANU MD SC
Entity Type:Organization
Organization Name:KIDANU BIRHANU MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIDANU
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRHANU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-334-2352
Mailing Address - Street 1:PO BOX 394
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-0394
Mailing Address - Country:US
Mailing Address - Phone:708-334-2352
Mailing Address - Fax:
Practice Address - Street 1:24 JOLIET ST
Practice Address - Street 2:SUITE 302
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1705
Practice Address - Country:US
Practice Address - Phone:219-852-2518
Practice Address - Fax:219-864-2156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-28
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066132A261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center