Provider Demographics
NPI:1356401616
Name:DEMISSACHEW, HAILU (MD)
Entity type:Individual
Prefix:
First Name:HAILU
Middle Name:
Last Name:DEMISSACHEW
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 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:19 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1533
Practice Address - Country:US
Practice Address - Phone:706-233-8504
Practice Address - Fax:706-233-8505
Is Sole Proprietor?:No
Enumeration Date:2006-12-09
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054072207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA413486161AMedicaid
GA413486161GMedicaid
GA413486161DMedicaid
GA413486161EMedicaid
GA413486161BMedicaid
GA413486161CMedicaid
GA413486161FMedicaid
GA413486161HMedicaid
GA413486161HMedicaid
GA39BDCHNMedicare ID - Type Unspecified