Provider Demographics
NPI:1578558714
Name:GEDEVANISHVILI, ALEXANDER T (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:T
Last Name:GEDEVANISHVILI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 SANDY PLAINS ROAD
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1602 VERNON RD STE 300
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240
Practice Address - Country:US
Practice Address - Phone:706-242-5100
Practice Address - Fax:706-812-2454
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054099207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA192405896AMedicaid
GA06BDHNCMedicare ID - Type Unspecified
GAI01540Medicare UPIN