Provider Demographics
NPI:1710073952
Name:BIRHANU, KIDANU (MD)
Entity Type:Individual
Prefix:
First Name:KIDANU
Middle Name:
Last Name:BIRHANU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KIDANU
Other - Middle Name:
Other - Last Name:BIRHANU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PC
Mailing Address - Street 1:24 JOLIET ST
Mailing Address - Street 2:STE 302
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1705
Mailing Address - Country:US
Mailing Address - Phone:219-852-2518
Mailing Address - Fax:219-864-2156
Practice Address - Street 1:24 JOLIET ST
Practice Address - Street 2:STE 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
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066132207R00000X
IL036072060207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072060Medicaid
IL01633358OtherBCBS OF IL
IL110248456OtherMEDICARE RAILROAD
IL110248456OtherMEDICARE RAILROAD
IL205043Medicare ID - Type Unspecified
IL036072060Medicaid
ILE47873Medicare UPIN