Provider Demographics
NPI:1376558767
Name:BEJANISHVILI, TAMAR (MD)
Entity Type:Individual
Prefix:
First Name:TAMAR
Middle Name:
Last Name:BEJANISHVILI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8792
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-8792
Mailing Address - Country:US
Mailing Address - Phone:440-735-2800
Mailing Address - Fax:440-786-2723
Practice Address - Street 1:50 BLAINE AVE
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:OH
Practice Address - Zip Code:44146-2782
Practice Address - Country:US
Practice Address - Phone:440-735-2800
Practice Address - Fax:440-786-2723
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079230207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2470624Medicaid
OH4127192Medicare PIN