Provider Demographics
NPI:1003059197
Name:EGRISELASHVILI, ANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:
Last Name:EGRISELASHVILI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:EGRISELASHVILI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6770 MAYFIELD RD
Mailing Address - Street 2:425
Mailing Address - City:MAYFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2299
Mailing Address - Country:US
Mailing Address - Phone:440-442-2040
Mailing Address - Fax:440-460-2807
Practice Address - Street 1:6770 MAYFIELD RD
Practice Address - Street 2:425
Practice Address - City:MAYFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44124-2299
Practice Address - Country:US
Practice Address - Phone:440-442-2040
Practice Address - Fax:440-460-2807
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35093484207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2998583Medicaid
OH4276311OtherMEDICARE ID- TYPE UNSPECIFIED