Basic Information
| Provider Information | |||||||||
| NPI: | 1083829527 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KIFLE ADMASSU MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 HAWKS RIDGE TRL | ||||||||
| Address2: | |||||||||
| City: | COLLEYVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760348213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179606648 | ||||||||
| FaxNumber: | 8179606649 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 HAWKS RIDGE TRL | ||||||||
| Address2: | |||||||||
| City: | COLLEYVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760348213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179606648 | ||||||||
| FaxNumber: | 8179606649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 06/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | ADMASSU | ||||||||
| AuthorizedOfficialFirstName: | KIFLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 8179606648 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | M1448 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | M1448 | 01 | TX | LICENSE | OTHER | 00X656 | 01 | TX | NEW MEDICARE NUMBER | OTHER | 612406 | 01 | TX | OTHER MEDICARE # | OTHER |