=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366826760
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDOM KIDANE MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2015
-----------------------------------------------------
Last Update Date | 08/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3237 S 16TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-389-4845
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3237 S 16TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53215-4526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-389-4845
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 67091
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------