Provider Demographics
NPI:1588962609
Name:GEBRESELLASSIE, ALEMAYEHU (ALEX) M (MLT)
Entity type:Individual
Prefix:MR
First Name:ALEMAYEHU (ALEX)
Middle Name:M
Last Name:GEBRESELLASSIE
Suffix:
Gender:M
Credentials:MLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 N MICHIGAN AVE STE 944E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2213
Mailing Address - Country:US
Mailing Address - Phone:312-202-0328
Mailing Address - Fax:312-202-0320
Practice Address - Street 1:845 N MICHIGAN AVE STE 944E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2213
Practice Address - Country:US
Practice Address - Phone:312-202-0328
Practice Address - Fax:312-202-0320
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D2018991246RM2200X, 247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL80-0668267OtherEIN #