Healthcare Provider Details

I. General information

NPI: 1164981007
Provider Name (Legal Business Name): DEREJE T SIYUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 05/17/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 N 12TH ST
MILWAUKEE WI
53233-1305
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-219-7427
  • Fax: 414-219-6078
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number74852-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number74852-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2083C0008X
TaxonomyClinical Informatics Physician
License Number74852-20
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number74852-20
License Number StateWI
# 5
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number74852
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: