=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306002449
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KASSAHUN TEFERA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2008
-----------------------------------------------------
Last Update Date | 03/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3422 GEORGIA AVE NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20001-4029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-413-1092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3422 GEORGIA AVE NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20010-2592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-413-1092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246QC1000X
-----------------------------------------------------
Taxonomy Name | Chemistry Pathology Specialist/Technologist
-----------------------------------------------------
License Number | 04213642
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 04213642
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------