Healthcare Provider Details

I. General information

NPI: 1366331118
Provider Name (Legal Business Name): AMANUEL PAULOS GENEBO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 EUCLID AVE
BERWYN IL
60402-3471
US

IV. Provider business mailing address

3231 EUCLID AVE STE 203
BERWYN IL
60402-6700
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-3401
  • Fax:
Mailing address:
  • Phone: 708-783-3401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125085940
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number12.085940
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: