Provider Demographics
NPI:1821452590
Name:TEKLEMARIAM, EPHREM REGASSA
Entity Type:Individual
Prefix:
First Name:EPHREM
Middle Name:REGASSA
Last Name:TEKLEMARIAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 NEW SCOTLAND AVENUE DEPT. OF MEDICINE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208
Mailing Address - Country:US
Mailing Address - Phone:571-275-3256
Mailing Address - Fax:
Practice Address - Street 1:47 NEW SCOTLAND AVENUE DEPT. OF MEDICINE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208
Practice Address - Country:US
Practice Address - Phone:571-275-3256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4702812084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY63810OtherDEPARTMENT ID NUMBER