Provider Demographics
NPI:1154749422
Name:GHEBRU WOLDEMICHAEL MD LLC
Entity type:Organization
Organization Name:GHEBRU WOLDEMICHAEL MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GHEBRU
Authorized Official - Middle Name:W
Authorized Official - Last Name:WOLDEMICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-317-9562
Mailing Address - Street 1:2851 S AVENUE B
Mailing Address - Street 2:SUITE 2601
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7726
Mailing Address - Country:US
Mailing Address - Phone:928-317-9562
Mailing Address - Fax:928-726-1588
Practice Address - Street 1:2851 S AVENUE B
Practice Address - Street 2:SUITE 2601
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7726
Practice Address - Country:US
Practice Address - Phone:928-317-9562
Practice Address - Fax:928-726-1588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAW3117454208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty