Provider Demographics
NPI:1639195076
Name:TESSEMA, EYOB (MD)
Entity Type:Individual
Prefix:DR
First Name:EYOB
Middle Name:
Last Name:TESSEMA
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 1:557 GLOVER AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2024
Mailing Address - Country:US
Mailing Address - Phone:334-347-7705
Mailing Address - Fax:334-347-7715
Practice Address - Street 1:557 GLOVER AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2024
Practice Address - Country:US
Practice Address - Phone:334-347-7705
Practice Address - Fax:334-347-7715
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL253312084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051534180OtherTROY - BCBS
AL051000552OtherSPS - BCBS
AL009979065Medicaid
AL009932531Medicaid
AL009937154Medicaid
AL009979865Medicaid
AL051000551OtherOSC - BCBS
AL051530196OtherEBHS - BCBS
AL009979865Medicaid
AL051000552OtherSPS - BCBS
AL051534180OtherTROY - BCBS
AL051555391Medicare UPIN