Midwest Dermpath LLC

Primary specialty

Dermatopathology (Pathology) PhysicianTaxonomy code 207ZD0900X

Legal business name

MIDWEST DERMPATH LLC

Practice address

409 Keller St
Bartonville, IL 61607-2556

Phone

(309) 404-6583

NPI assigned

Nov 27, 2023

Last updated

Jan 31, 2024By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Tesfu Hailu, MD

Title

Lab Director

Phone

(309) 404-6583

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1701043200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1706659200000",
    "number": "1194591529",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "409 KELLER ST",
            "city": "BARTONVILLE",
            "state": "IL",
            "postal_code": "616072556",
            "telephone_number": "309-404-6583"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "409 KELLER ST",
            "city": "BARTONVILLE",
            "state": "IL",
            "postal_code": "616072556",
            "telephone_number": "309-404-6583"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MIDWEST DERMPATH LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-11-27",
        "last_updated": "2024-01-31",
        "certification_date": "2024-01-31",
        "status": "A",
        "authorized_official_last_name": "HAILU",
        "authorized_official_first_name": "TESFU",
        "authorized_official_title_or_position": "LAB DIRECTOR",
        "authorized_official_telephone_number": "309-404-6583",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207ZD0900X",
            "taxonomy_group": "",
            "desc": "Pathology, Dermatopathology",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207ZP0102X",
            "taxonomy_group": "",
            "desc": "Pathology, Anatomic Pathology & Clinical Pathology",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Dermatopathology (Pathology) Physician in Bartonville, IL
• Providers in Bartonville, IL by specialty
• Dermatopathology (Pathology) Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 31, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.