Basic Information
| Provider Information | |||||||||
| NPI: | 1518534452 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENGSTEAB | ||||||||
| FirstName: | MEHRETEAB | ||||||||
| MiddleName: | YACOB | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 260 JEFFERSON AVE SE STE 305 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166854615 | ||||||||
| FaxNumber: | 6166853033 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 LAFAYETTE AVE SE STE 3000 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166856919 | ||||||||
| FaxNumber: | 6166853063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2021 | ||||||||
| LastUpdateDate: | 06/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4351048777 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.