Healthcare Provider Details

I. General information

NPI: 1437653904
Provider Name (Legal Business Name): AEDOME GIRMA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 DEVONSHIRE ST STE 500
BOSTON MA
02110-1407
US

IV. Provider business mailing address

45 SPRING ST APT 11
BOSTON MA
02132-3949
US

V. Phone/Fax

Practice location:
  • Phone: 617-356-7112
  • Fax: 617-415-2769
Mailing address:
  • Phone: 617-335-5096
  • Fax: 617-415-2769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number290850
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: