Provider Demographics
NPI:1891890406
Name:TESFAU, SIMON HAILESELASSIE (MD)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:HAILESELASSIE
Last Name:TESFAU
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:PO BOX 1000, DEPT 978
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-758-9900
Mailing Address - Fax:901-752-2335
Practice Address - Street 1:3473 POPLAR AVE STE 103
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-4654
Practice Address - Country:US
Practice Address - Phone:901-320-6915
Practice Address - Fax:901-320-6920
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41174208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1510458Medicaid
TN103I115939Medicare PIN