1235392937 NPI number — KHATUNA GURGENASHVILI MD

Table of content: KHATUNA GURGENASHVILI MD (NPI 1235392937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235392937 NPI number — KHATUNA GURGENASHVILI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GURGENASHVILI
Provider First Name:
KHATUNA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1235392937
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3421 CONCORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17402-9001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-797-9240
Provider Business Mailing Address Fax Number:
301-797-0008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 ST PAUL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMBERSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17201-1036
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:
301-797-0008
Provider Enumeration Date:
07/03/2008

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: 2084N0400X , with the licence number:  D0070249 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: MD439112 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00945562 . This is a "MEDICARE RR MD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: W2660029 . This is a "BCBS REGIONAL CAREFIRST W266" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 2544895 . This is a "BCBS FREEDOM BLUE PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2544895 . This is a "HIGHMARK BCBS MARYLAND POS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: P00945563 . This is a "MEDICARE RR PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 445117100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 972589 . This is a "BCBS LOCAL CAREFIRST KG85" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 103326162 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2544895 . This is a "HIGHMARK BCBS PENNSYLVANIA POS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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