Healthcare Provider Details

I. General information

NPI: 1932691631
Provider Name (Legal Business Name): PHILIPOS KIDANE GEBREMEDHIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 N RUTLEDGE ST FL 4
SPRINGFIELD IL
62702-6700
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-7053
Mailing address:
  • Phone: 217-545-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036.174691
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: