Provider Demographics
NPI:1912991928
Name:HAILESELASSIE, MULUMEBET (MD)
Entity Type:Individual
Prefix:
First Name:MULUMEBET
Middle Name:
Last Name:HAILESELASSIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W RIVER DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52801-1014
Mailing Address - Country:US
Mailing Address - Phone:563-336-3000
Mailing Address - Fax:563-336-3125
Practice Address - Street 1:500 W RIVER DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52801-1014
Practice Address - Country:US
Practice Address - Phone:563-336-3000
Practice Address - Fax:563-336-3125
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27414207V00000X
IL036-053422207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0080200Medicaid
IL421060724002Medicaid
IL8122859OtherILLINOIS BC/BS
IA291468OtherIOWA BC/BS
IA42106072428OtherJOHN DEERE HEALTH
070573OtherHEALTH ALLIANCE #
IA1234295OtherCONTROLLED SUBSTANCE#
IAIA0128OtherJOHN DEERE EDI#
IA421060724OtherBILLING TAX ID# FOR CHC
IA421060724OtherBILLING TAX ID# FOR CHC
IA291468OtherIOWA BC/BS
IA29146Medicare ID - Type UnspecifiedIOWA MEDICARE PART B
IL421060724002Medicaid
IA0080200Medicaid