Provider Demographics
NPI:1801958616
Name:SOLOMON AMDEMARIAM LLC
Entity type:Organization
Organization Name:SOLOMON AMDEMARIAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOLOMON
Authorized Official - Middle Name:
Authorized Official - Last Name:AMDEMARIAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-698-6741
Mailing Address - Street 1:20280 N 59TH AVE
Mailing Address - Street 2:SUITE # 115 PMB 544
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6850
Mailing Address - Country:US
Mailing Address - Phone:623-594-7866
Mailing Address - Fax:
Practice Address - Street 1:2000 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2443
Practice Address - Country:US
Practice Address - Phone:623-594-7866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31855207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H57002Medicare UPIN