Provider Demographics
NPI:1760739908
Name:CHUBINIDZEMD PLLC
Entity Type:Organization
Organization Name:CHUBINIDZEMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OMARI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUBINIDZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-244-5252
Mailing Address - Street 1:1306 OLD TAYLOR TRL
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:KY
Mailing Address - Zip Code:40026-9727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1306 OLD TAYLOR TRL
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:KY
Practice Address - Zip Code:40026-9727
Practice Address - Country:US
Practice Address - Phone:502-244-5252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41262207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty