Provider Demographics
NPI:1285994251
Name:MEMORIAL DRIVE FAMILY MEDICINE P.C
Entity type:Organization
Organization Name:MEMORIAL DRIVE FAMILY MEDICINE P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TASSEW
Authorized Official - Middle Name:
Authorized Official - Last Name:TESFAYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-809-2480
Mailing Address - Street 1:4958 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-4148
Mailing Address - Country:US
Mailing Address - Phone:404-809-2480
Mailing Address - Fax:404-809-2485
Practice Address - Street 1:4958 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-4148
Practice Address - Country:US
Practice Address - Phone:404-809-2480
Practice Address - Fax:404-809-2485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-23
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty