=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477794576
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ETHIO-AMERICAN HEALTH CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2009
-----------------------------------------------------
Last Update Date | 03/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4515 14TH ST NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20011-4358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-607-1763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 21425
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20009-0925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-607-1763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | PAIGE SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-509-4091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | MD034616
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD035167
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD034563
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------