Healthcare Provider Details

I. General information

NPI: 1144042896
Provider Name (Legal Business Name): EYRUSALAM GEBREMICHAEL GEBREMEDHINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 10/24/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S EXETER ST
BALTIMORE MD
21202-4316
US

IV. Provider business mailing address

630 S EXETER ST
BALTIMORE MD
21202-4316
US

V. Phone/Fax

Practice location:
  • Phone: 410-962-5620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR258010
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: