MEDICARE: SAMEL T GEBRESILASIE

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	343900000X	Non-emergency Medical Transport (VAN)	057597061	GA

General Provider Information

NPI Number	:	1952168254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMEL T GEBRESILASIE

Provider Business Mailing Address
First Line	:	2053 MARTIN LUTHER KING JR DR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-1165
Country	:	US
Telephone Number	:	404-513-6908
Fax Number	:

Provider Business Practice Location Address
First Line	:	2053 MARTIN LUTHER KING JR DR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-1165
Country	:	US
Telephone Number	:	404-513-6908
Fax Number	:

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

Provider Enumeration Date	:	03/04/2024
Last Update Date	:	03/04/2024

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Directions to “ SAMEL T GEBRESILASIE ” Practice Location

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