Healthcare Provider Details

I. General information

NPI: 1891547683
Provider Name (Legal Business Name): BEREKET A GEBREGZIABHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 06/15/2025
Certification Date: 06/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 HARVESTER DR STE 110
BURR RIDGE IL
60527-6686
US

IV. Provider business mailing address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1150
  • Fax:
Mailing address:
  • Phone: 773-702-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.085568
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: