Healthcare Provider Details

I. General information

NPI: 1861381444
Provider Name (Legal Business Name): TSEGAYE WESENSEGED GEBREAMLAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

3722 HARLEM AVE
RIVERSIDE IL
60546-2312
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-6566
  • Fax: 708-783-6567
Mailing address:
  • Phone: 708-783-6566
  • Fax: 708-783-6567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125084739
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.084739
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: