1679779409 NPI number — NINO DGEBUADZE M.D., PH.D.

Table of content: NINO DGEBUADZE M.D., PH.D. (NPI 1679779409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679779409 NPI number — NINO DGEBUADZE M.D., PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DGEBUADZE
Provider First Name:
NINO
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D., PH.D.
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:
1679779409
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4444 FOREST PARK AVE
Provider Second Line Business Mailing Address:
CAMPUS BOX 8518
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63108-8518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-454-7757
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 WESTERN MARYLAND PKWY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
HAGERSTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-797-9240
Provider Business Practice Location Address Fax Number:
301-797-4119
Provider Enumeration Date:
06/27/2007

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: 208100000X , with the licence number:  D0073349 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208100000X , with the licence number: 2007012244 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 97628601 . This is a "BCBS LOCAL CAREFIRST KG85" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 333505400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: W2660030 . This is a "BCBS REGIONAL W266" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: P01024230 . This is a "RR MEDICARE MD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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