Healthcare Provider Details

I. General information

NPI: 1215195748
Provider Name (Legal Business Name): INDRYAS LEMMA WOLDIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2008
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 ST. ANTOINE SUITE 7B
DETROIT MI
48201-2153
US

IV. Provider business mailing address

1420 STEPHENSON HWY SUITE 400-CREDENTIALING
TROY MI
48083-1189
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-2554
  • Fax: 313-993-0295
Mailing address:
  • Phone: 248-581-5977
  • Fax: 248-581-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301088450
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number4301088450
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: