Basic Information
Provider Information | |||||||||
NPI: | 1194088302 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GELETA | ||||||||
FirstName: | NIGUSSIE | ||||||||
MiddleName: | ALEMU | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1007 E WEST HWY | ||||||||
Address2: |   | ||||||||
City: | TAKOMA PARK | ||||||||
State: | MD | ||||||||
PostalCode: | 209125931 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2404624888 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 112 N 7TH ST | ||||||||
Address2: |   | ||||||||
City: | CHAMBERSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 172011720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172174300 | ||||||||
FaxNumber: | 7172174217 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2012 | ||||||||
LastUpdateDate: | 06/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101258256 | VA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD456681 | PA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | D0079566 | MD | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 208M00000X | MD456681 | PA | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 1194088302 | 05 | VA |   | MEDICAID |