MEDICARE: EDEN ASEFAW GHEBRESILASIE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA3418	FL

General Provider Information

NPI Number	:	1164591400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDEN ASEFAW GHEBRESILASIE PA

Provider Business Mailing Address
First Line	:	2642 COLLINS AVE
Second Line	:	APT 207
City	:	MIAMI BEACH
State	:	FL
Zip	:	33140
Country	:	US
Telephone Number	:	305-215-2929
Fax Number	:

Provider Business Practice Location Address
First Line	:	18260 NE 19TH AVE
Second Line	:	SUITE 201
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33162-1632
Country	:	US
Telephone Number	:	305-956-9062
Fax Number	:	305-354-4524

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	06/06/2008

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