MEDICARE: MR. ALEMAYEHU (ALEX) M GEBRESELLASSIE MLT

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	246RM2200X	Medical Laboratory Technician	14D2018991	IL
2	247ZC0005X	Clinical Laboratory Director (Non-physician)	14D2018991	IL

General Provider Information

NPI Number	:	1588962609
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALEMAYEHU (ALEX) M GEBRESELLASSIE MLT

Provider Business Mailing Address
First Line	:	845 N MICHIGAN AVE STE 944E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2213
Country	:	US
Telephone Number	:	312-202-0328
Fax Number	:	312-202-0320

Provider Business Practice Location Address
First Line	:	845 N MICHIGAN AVE STE 944E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2213
Country	:	US
Telephone Number	:	312-202-0328
Fax Number	:	312-202-0320

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

Provider Enumeration Date	:	03/14/2011
Last Update Date	:	03/14/2011

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