Basic Information
| Provider Information | |||||||||
| NPI: | 1518977198 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHANIDZE | ||||||||
| FirstName: | IRINA | ||||||||
| MiddleName: | OMARIEVNA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29275 W 10 MILE RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483362817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483502722 | ||||||||
| FaxNumber: | 2483500154 | ||||||||
| Practice Location | |||||||||
| Address1: | 29275 W 10 MILE RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483362817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483502722 | ||||||||
| FaxNumber: | 2483500154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 12/14/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 4301078150 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 4301078150 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 0F37521 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 1518977198 | 05 | MI | MEDICAID |