Healthcare Provider Details

I. General information

NPI: 1588344923
Provider Name (Legal Business Name): HERMON H GHEBREMEDHIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4832 W BROAD ST
COLUMBUS OH
43228-1971
US

IV. Provider business mailing address

754 TATRA CT
REYNOLDSBURG OH
43068-4755
US

V. Phone/Fax

Practice location:
  • Phone: 614-465-7457
  • Fax:
Mailing address:
  • Phone: 614-743-5699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0010201
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.008142RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: