Healthcare Provider Details

I. General information

NPI: 1043988306
Provider Name (Legal Business Name): SARA KEBEDE MD, MSCR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2021
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 N RUTLEDGE ST
SPRINGFIELD IL
62702-6700
US

IV. Provider business mailing address

PO BOX 19653
SPRINGFIELD IL
62794-9653
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-6112
  • Fax: 217-545-2588
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number125.083225
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number125.083225
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: