Basic Information
| Provider Information | |||||||||
| NPI: | 1184779415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEYSSA | ||||||||
| FirstName: | EYOB | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MPH, FACP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5401 OLD YORK RD | ||||||||
| Address2: | KLEIN SUITE 505 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154568242 | ||||||||
| FaxNumber: | 2154568058 | ||||||||
| Practice Location | |||||||||
| Address1: | 5401 OLD YORK RD | ||||||||
| Address2: | KLEIN SUITE 505 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154568242 | ||||||||
| FaxNumber: | 2154568058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0008X | M5704 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hepatology | 207RI0008X | 25MA08117400 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hepatology | 207R00000X | MD430800 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | MD430800 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RI0008X | MD430800 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hepatology |
ID Information
| ID | Type | State | Issuer | Description | 101978752 | 05 | PA | MEDICAID |