Provider Demographics
NPI:1124074513
Name:TEBEJE, LEGESSE F (MD)
Entity type:Individual
Prefix:DR
First Name:LEGESSE
Middle Name:F
Last Name:TEBEJE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 52007
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30355-0007
Mailing Address - Country:US
Mailing Address - Phone:678-397-0060
Mailing Address - Fax:678-397-0065
Practice Address - Street 1:1170 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3615
Practice Address - Country:US
Practice Address - Phone:404-466-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20990207R00000X
GA58228207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576007863110OtherBCBS OF SC ID
SC576007863071OtherBLUECHOICE HEALTHPLAN ID
SCT53420Medicaid
SC6919559OtherCIGNA ID
SC7349013OtherAETNA ID
SC576007863071OtherBLUECHOICE HEALTHPLAN ID
SCT53420Medicaid