1447246509 NPI number — DR. NANA S AMIRIDZE MD, PHD

Table of content: DR. NANA S AMIRIDZE MD, PHD (NPI 1447246509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447246509 NPI number — DR. NANA S AMIRIDZE MD, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AMIRIDZE
Provider First Name:
NANA
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447246509
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 561600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLEDGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32956-1600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-434-4660
Provider Business Mailing Address Fax Number:
321-259-0635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1251 S HICKORY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-3221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-434-3420
Provider Business Practice Location Address Fax Number:
321-434-3423
Provider Enumeration Date:
09/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  D0060165 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: ME105768 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X , with the licence number: ME105768 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 405376100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 60340002 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 0063 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 001680100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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