Provider Demographics
NPI:1336105535
Name:TAREKEGNE, MULUGETA (MD)
Entity Type:Individual
Prefix:
First Name:MULUGETA
Middle Name:
Last Name:TAREKEGNE
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 1:2719 MIDDLEBURG DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2414
Mailing Address - Country:US
Mailing Address - Phone:803-256-6828
Mailing Address - Fax:803-256-6827
Practice Address - Street 1:2719 MIDDLEBURG DR
Practice Address - Street 2:SUITE 201
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2414
Practice Address - Country:US
Practice Address - Phone:803-256-6828
Practice Address - Fax:803-256-6827
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21648207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3800OtherGROUP MCAID NUMBER
SC216484Medicaid
SCGP3800OtherGROUP MCAID NUMBER
SC216484Medicaid
SCSC0590F694Medicare PIN
SCH090287805Medicare ID - Type Unspecified
SCSC05909068Medicare PIN
SC731669589OtherTAX ID NUMBER