Provider Demographics
NPI:1184945750
Name:BELAYNEH, DEREJE KETEMA
Entity type:Individual
Prefix:DR
First Name:DEREJE
Middle Name:KETEMA
Last Name:BELAYNEH
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 1:77 W HURON ST
Mailing Address - Street 2:APT# 1610
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-2852
Mailing Address - Country:US
Mailing Address - Phone:617-849-0757
Mailing Address - Fax:
Practice Address - Street 1:251 E HURON ST
Practice Address - Street 2:GALTER 3-150
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:312-926-2253
Practice Address - Fax:312-926-6905
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125058002207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine