Provider Demographics
NPI:1508959693
Name:TCHELIDZE, TEA (MD)
Entity Type:Individual
Prefix:
First Name:TEA
Middle Name:
Last Name:TCHELIDZE
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 92938
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-2938
Mailing Address - Country:US
Mailing Address - Phone:440-466-4641
Mailing Address - Fax:440-466-1871
Practice Address - Street 1:254 S BROADWAY
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:OH
Practice Address - Zip Code:44041-1807
Practice Address - Country:US
Practice Address - Phone:216-383-0100
Practice Address - Fax:216-383-6481
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35085308207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H65362Medicare UPIN