Provider Demographics
NPI:1982930517
Name:SELAM MEDICAL SERVICE LLC
Entity Type:Organization
Organization Name:SELAM MEDICAL SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSOM
Authorized Official - Middle Name:BARIAGHABER
Authorized Official - Last Name:GHEBRAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-502-6912
Mailing Address - Street 1:603 SLIGO AVE
Mailing Address - Street 2:APT 313
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-4765
Mailing Address - Country:US
Mailing Address - Phone:301-588-0724
Mailing Address - Fax:
Practice Address - Street 1:1328 SOUTHERN AVE SE
Practice Address - Street 2:SUITE 205
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4689
Practice Address - Country:US
Practice Address - Phone:202-544-7744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD035237207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC059550700Medicaid
DC059550700Medicaid