Provider Demographics
NPI:1679318877
Name:WELDEMICHAEL, GENET HAGOS
Entity type:Individual
Prefix:
First Name:GENET
Middle Name:HAGOS
Last Name:WELDEMICHAEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3471
Mailing Address - Country:US
Mailing Address - Phone:708-783-3401
Mailing Address - Fax:708-783-3341
Practice Address - Street 1:3231 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3471
Practice Address - Country:US
Practice Address - Phone:708-783-3401
Practice Address - Fax:708-783-3341
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.083841207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine