=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194591529
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWEST DERMPATH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2023
-----------------------------------------------------
Last Update Date | 01/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 409 KELLER ST
-----------------------------------------------------
City | BARTONVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61607-2556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-404-6583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 409 KELLER ST
-----------------------------------------------------
City | BARTONVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61607-2556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-404-6583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LAB DIRECTOR
-----------------------------------------------------
Name | TESFU HAILU
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 309-404-6583
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ZD0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology (Pathology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------