Provider Demographics
NPI:1902814452
Name:GARIBASHVILY, ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:
Last Name:GARIBASHVILY
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 1:537 CHARLEMAGNE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2109
Mailing Address - Country:US
Mailing Address - Phone:847-850-5377
Mailing Address - Fax:847-850-5378
Practice Address - Street 1:200 MILWAUKEE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-2812
Practice Address - Country:US
Practice Address - Phone:847-850-5377
Practice Address - Fax:847-850-5378
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112246Medicaid
IL036112246Medicaid
ILK18185Medicare PIN