Provider Demographics
NPI:1477155158
Name:MAYA BERDZENISHVILI MD LLC
Entity Type:Organization
Organization Name:MAYA BERDZENISHVILI MD LLC
Other - Org Name:MAYA BERDZENISHVILI MD LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERDZENISHVILI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-262-0462
Mailing Address - Street 1:220 COMMONWEALTH AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-2510
Mailing Address - Country:US
Mailing Address - Phone:617-262-6402
Mailing Address - Fax:617-262-6402
Practice Address - Street 1:220 COMMONWEALTH AVE APT 4
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-2510
Practice Address - Country:US
Practice Address - Phone:617-262-6402
Practice Address - Fax:617-262-6402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-09
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Multi-Specialty