Provider Demographics
NPI:1508078023
Name:MAGHLAKELIDZE, TEONA (MD)
Entity Type:Individual
Prefix:DR
First Name:TEONA
Middle Name:
Last Name:MAGHLAKELIDZE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4401 CAMPUS RIDGE DR STE 1100
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6125
Mailing Address - Country:US
Mailing Address - Phone:989-837-9200
Mailing Address - Fax:989-837-9205
Practice Address - Street 1:4401 CAMPUS RIDGE DR STE 1100
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6125
Practice Address - Country:US
Practice Address - Phone:989-837-9200
Practice Address - Fax:989-837-9205
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083483207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5175850Medicaid
381908328 076OtherCOMMUNITY CHOICE OF MI
381908328 385OtherCOMMUNITY CHOICE OF MI
MI1107312852OtherBLUE CROSS INDIVIDUAL
381908328 383OtherCOMMUNITY CHOICE OF MI
381908328 384OtherCOMMUNITY CHOICE OF MI
MI5175823OtherMEDICAID TYPE 77
700G361110OtherBLUE CARE NETWORK
MI700G361110OtherBLUE CROSS GROUP
1026132OtherMCLAREN HEALTH PLAN
1026133OtherMCLAREN HEALTH PLAN
MI1107312852OtherBLUE CROSS TRUST
161377OtherGREAT LAKES HEALTH PLAN
1026134OtherMCLAREN HEALTH PLAN
MI700G361110OtherBLUE CROSS
01006116OtherHEALTHPLUS OF MICHIGAN
1026135OtherMCLAREN HEALTH PLAN
381908328OtherAETNA
381908328 386OtherCOMMUNITY CHOICE OF MI
381908328 385OtherCOMMUNITY CHOICE OF MI