Basic Information
| Provider Information | |||||||||
| NPI: | 1215225552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALANCHIVADZE | ||||||||
| FirstName: | NINO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6350 CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235024107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579055558 | ||||||||
| FaxNumber: | 7572135762 | ||||||||
| Practice Location | |||||||||
| Address1: | 6251 E VIRGINIA BEACH BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235022800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574668683 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2011 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 36560 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 4301117273 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RH0003X | 0101274592 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.