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General NPI Number Information
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NPI Number | 1194619197
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Entity Type | Individual
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Provider Name | WEGAHTA KIDANE GHEBREIYESUS MD
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Gender | Female
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Dates
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Enumeration Date | 06/04/2025
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Last Update Date | 08/11/2025
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Provider Practice Location Address
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Address Line | 300 LAFAYETTE AVE SUITE 3000
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City | GRAND RAPIDS
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State | MI
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Zip | 49503
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Country | US
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Telephone | 616-685-6919
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Fax | 616-685-3063
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Provider Business Mailing Address
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Address Line | 200 JEFFERSON AVE SUITE 305
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City | GRAND RAPIDS
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State | MI
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Zip | 49503
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Country | US
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Telephone | 616-685-4615
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Fax | 616-685-3033
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 4351054941
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License Number State | MI
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