Healthcare Provider Details

I. General information

NPI: 1780983320
Provider Name (Legal Business Name): NEBIYU Y BIRU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 UNION AVE
SHEBOYGAN WI
53081-8426
US

IV. Provider business mailing address

4902 DONOVAN DR
ALEXANDRIA VA
22304-8606
US

V. Phone/Fax

Practice location:
  • Phone: 920-828-2700
  • Fax:
Mailing address:
  • Phone: 732-939-7248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number0101258331
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number57607
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number0101258331
License Number StateVA
# 5
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number57607
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: