Provider Demographics
NPI:1023297397
Name:TESFAI, MEBRAHTOM W (MD)
Entity type:Individual
Prefix:
First Name:MEBRAHTOM
Middle Name:W
Last Name:TESFAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MEBRAHTOM
Other - Middle Name:W
Other - Last Name:TESFAI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 23321
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-4321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 W MEETING ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-2202
Practice Address - Country:US
Practice Address - Phone:803-286-1214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD40101207R00000X
NC2007-01772207R00000X
SC40101207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2318Medicaid
NC5908266Medicaid
NC1023297397Medicaid
NC14722OtherBCBS
NCP00479792OtherRR MCARE
NC14722OtherBCBS
NCNCM461CMedicare PIN
NC5908266Medicaid
NC1023297397Medicaid
SCNC2318Medicaid