Healthcare Provider Details

I. General information

NPI: 1063415388
Provider Name (Legal Business Name): TIGIST HAILU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 02/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4924 CAMPBELL BLVD STE 110
BALTIMORE MD
21236-5908
US

IV. Provider business mailing address

PO BOX 64250
BALTIMORE MD
21264-4250
US

V. Phone/Fax

Practice location:
  • Phone: 443-442-2000
  • Fax: 443-442-2018
Mailing address:
  • Phone: 410-502-0550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD0061065
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: