Basic Information
| Provider Information | |||||||||
| NPI: | 1912292525 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENGISTU | ||||||||
| FirstName: | YOHANNES | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MENGISTU | ||||||||
| OtherFirstName: | YOHANNES | ||||||||
| OtherMiddleName: | TILAHUN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 213 S JEFFERSON ST STE 625 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240111713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245516 | ||||||||
| FaxNumber: | 5402245684 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 LAMB CIR | ||||||||
| Address2: | |||||||||
| City: | CHRISTIANSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240736344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407312000 | ||||||||
| FaxNumber: | 5407312659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2011 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 0101255669 | VA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 0101255669 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.