Healthcare Provider Details

I. General information

NPI: 1366632713
Provider Name (Legal Business Name): WIHIB AMBAYE GEBREGEORGIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 JOHN R, SUITE 917 HARPER PROFESSIONAL BUILDING
DETROIT MI
48201-2020
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 313-745-4525
  • Fax: 313-745-0011
Mailing address:
  • Phone: 248-581-5972
  • Fax: 248-581-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301087251
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number4301087251
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: