Healthcare Provider Details

I. General information

NPI: 1194591529
Provider Name (Legal Business Name): MIDWEST DERMPATH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 KELLER ST
BARTONVILLE IL
61607-2556
US

IV. Provider business mailing address

409 KELLER ST
BARTONVILLE IL
61607-2556
US

V. Phone/Fax

Practice location:
  • Phone: 309-404-6583
  • Fax:
Mailing address:
  • Phone: 309-404-6583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: TESFU HAILU
Title or Position: LAB DIRECTOR
Credential: MD
Phone: 309-404-6583