Provider Demographics
NPI:1871510842
Name:TSUTSKIRIDZE, IVAN (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:TSUTSKIRIDZE
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 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-728-2844
Mailing Address - Fax:215-214-1425
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:215-728-2844
Practice Address - Fax:215-214-1425
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9781207R00000X
PAMD444322208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3865276000OtherKEYSTONE IBC
PA1026484200001Medicaid
ND24668OtherNORTH DAKOTA BLUE SHIELD
PA2669208OtherHIGHMARK BLUE SHIELD
ND13141Medicaid
I10949Medicare UPIN
PA2669208OtherHIGHMARK BLUE SHIELD
P0028239Medicare ID - Type UnspecifiedRAILROAD MEDICARE
ND13141Medicaid