Provider Demographics
NPI:1194591529
Name:MIDWEST DERMPATH LLC
Entity type:Organization
Organization Name:MIDWEST DERMPATH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAB DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TESFU
Authorized Official - Middle Name:
Authorized Official - Last Name:HAILU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-404-6583
Mailing Address - Street 1:409 KELLER ST
Mailing Address - Street 2:
Mailing Address - City:BARTONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61607-2556
Mailing Address - Country:US
Mailing Address - Phone:309-404-6583
Mailing Address - Fax:
Practice Address - Street 1:409 KELLER ST
Practice Address - Street 2:
Practice Address - City:BARTONVILLE
Practice Address - State:IL
Practice Address - Zip Code:61607-2556
Practice Address - Country:US
Practice Address - Phone:309-404-6583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-27
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty