Healthcare Provider Details

I. General information

NPI: 1912463381
Provider Name (Legal Business Name): BERHANE GEBRESELASSIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 NORTH ST
HARRISON NY
10528-1140
US

IV. Provider business mailing address

275 NORTH ST
HARRISON NY
10528-1140
US

V. Phone/Fax

Practice location:
  • Phone: 914-967-6500
  • Fax:
Mailing address:
  • Phone: 914-967-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number707362-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: