Provider Demographics
NPI:1750750741
Name:ABRAHAM INFECTIOUS DISEASE ASSOCIATES LLC
Entity type:Organization
Organization Name:ABRAHAM INFECTIOUS DISEASE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GIZATCHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:KETSELA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-240-5850
Mailing Address - Street 1:2024 E PINETREE BLVD STE H
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5391
Mailing Address - Country:US
Mailing Address - Phone:229-236-3339
Mailing Address - Fax:229-236-3337
Practice Address - Street 1:2024 E PINETREE BLVD STE H
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5391
Practice Address - Country:US
Practice Address - Phone:229-236-3339
Practice Address - Fax:229-236-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-19
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA71980174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA102G701054Medicare PIN