1508078023 NPI number — DR. TEONA MAGHLAKELIDZE MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508078023 NPI number — DR. TEONA MAGHLAKELIDZE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAGHLAKELIDZE
Provider First Name:
TEONA
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
1508078023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4401 CAMPUS RIDGE DR STE 1100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48640-6125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-837-9200
Provider Business Mailing Address Fax Number:
989-837-9205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4401 CAMPUS RIDGE DR STE 1100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48640-6125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-837-9200
Provider Business Practice Location Address Fax Number:
989-837-9205
Provider Enumeration Date:
05/04/2007

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: 207R00000X , with the licence number:  4301083483 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5175850 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 381908328 076 . This is a "COMMUNITY CHOICE OF MI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 381908328 385 . This is a "COMMUNITY CHOICE OF MI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1107312852 . This is a "BLUE CROSS INDIVIDUAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 381908328 383 . This is a "COMMUNITY CHOICE OF MI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 381908328 384 . This is a "COMMUNITY CHOICE OF MI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5175823 . This is a "MEDICAID TYPE 77" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700G361110 . This is a "BLUE CARE NETWORK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 700G361110 . This is a "BLUE CROSS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1026132 . This is a "MCLAREN HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1026133 . This is a "MCLAREN HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1107312852 . This is a "BLUE CROSS TRUST" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 161377 . This is a "GREAT LAKES HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1026134 . This is a "MCLAREN HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 700G361110 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 01006116 . This is a "HEALTHPLUS OF MICHIGAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1026135 . This is a "MCLAREN HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 381908328 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 381908328 386 . This is a "COMMUNITY CHOICE OF MI" identifier . This identifiers is of the category "OTHER".




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