Healthcare Provider Details

I. General information

NPI: 1952168254
Provider Name (Legal Business Name): SAMEL T GEBRESILASIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2053 MARTIN LUTHER KING JR DR SW
ATLANTA GA
30310-1165
US

IV. Provider business mailing address

2053 MARTIN LUTHER KING JR DR SW
ATLANTA GA
30310-1165
US

V. Phone/Fax

Practice location:
  • Phone: 404-513-6908
  • Fax:
Mailing address:
  • Phone: 404-513-6908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number057597061
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: