MEDICARE: MR. AMANUEL Z GHEBREMEDHIN

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	172A00000X	Driver

General Provider Information

NPI Number	:	1669172037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. AMANUEL Z GHEBREMEDHIN

Provider Business Mailing Address
First Line	:	3646 WISH AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-3690
Country	:	US
Telephone Number	:	317-332-2096
Fax Number	:

Provider Business Practice Location Address
First Line	:	3646 WISH AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-3690
Country	:	US
Telephone Number	:	317-332-2096
Fax Number	:

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

Provider Enumeration Date	:	03/06/2023
Last Update Date	:	03/08/2023

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