Healthcare Provider Details

I. General information

NPI: 1528403805
Provider Name (Legal Business Name): SEMERE TEDLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MADISON ST
JOLIET IL
60435-8200
US

IV. Provider business mailing address

1270S BLUE ISLAND AVE 101
CHICAGO IL
60608-2284
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-7133
  • Fax:
Mailing address:
  • Phone: 216-272-5955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036139955
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: