Provider Demographics
NPI:1558982124
Name:MAISURADZE, EKA
Entity Type:Individual
Prefix:
First Name:EKA
Middle Name:
Last Name:MAISURADZE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8336 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-1909
Mailing Address - Country:US
Mailing Address - Phone:215-742-9811
Mailing Address - Fax:
Practice Address - Street 1:8336 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-1909
Practice Address - Country:US
Practice Address - Phone:215-742-9811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174200000XOther Service ProvidersMeals