Healthcare Provider Details

I. General information

NPI: 1588962609
Provider Name (Legal Business Name): ALEMAYEHU (ALEX) M GEBRESELLASSIE MLT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2011
Last Update Date: 03/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 N MICHIGAN AVE STE 944E
CHICAGO IL
60611-2213
US

IV. Provider business mailing address

845 N MICHIGAN AVE STE 944E
CHICAGO IL
60611-2213
US

V. Phone/Fax

Practice location:
  • Phone: 312-202-0328
  • Fax: 312-202-0320
Mailing address:
  • Phone: 312-202-0328
  • Fax: 312-202-0320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number14D2018991
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number14D2018991
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: