Healthcare Provider Details

I. General information

NPI: 1497984660
Provider Name (Legal Business Name): MUSSIE GEBREMEDIHN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1468 MONTREAL RD
TUCKER GA
30084-6901
US

IV. Provider business mailing address

1468 MONTREAL RD
TUCKER GA
30084-6901
US

V. Phone/Fax

Practice location:
  • Phone: 770-638-1400
  • Fax: 770-638-1411
Mailing address:
  • Phone: 770-638-1400
  • Fax: 770-638-1411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD2016-0240
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number86427
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: