MEDICARE: RAKEB TEMESELEW MAMO

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1275460206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAKEB TEMESELEW MAMO

Provider Business Mailing Address
First Line	:	YEKA B180 14
Second Line	:
City	:	ADDIS ABABA
State	:	ADDIS ABABA
Zip	:	10000
Country	:	ET
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	355 BARD AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10310
Country	:	US
Telephone Number	:	710-818-1234
Fax Number	:

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

Provider Enumeration Date	:	05/05/2026
Last Update Date	:	05/05/2026

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Directions to “ RAKEB TEMESELEW MAMO ” Practice Location

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