Provider Demographics
NPI:1790390292
Name:OMARI CHUBINIDZE MEDICAL PC
Entity Type:Organization
Organization Name:OMARI CHUBINIDZE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OMARI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUBINIDZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-836-4318
Mailing Address - Street 1:100 NEWBRIDGE RD STE 6
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-3948
Mailing Address - Country:US
Mailing Address - Phone:516-882-7473
Mailing Address - Fax:
Practice Address - Street 1:100 NEWBRIDGE RD STE 6
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-3948
Practice Address - Country:US
Practice Address - Phone:516-882-7473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty