Healthcare Provider Details

I. General information

NPI: 1942418017
Provider Name (Legal Business Name): GELA G MCHEDLISHVILI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2007
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12660 RIVERSIDE DR STE 215
NORTH HOLLYWOOD CA
91607-3430
US

IV. Provider business mailing address

3421 CONCORD RD
YORK PA
17402-9001
US

V. Phone/Fax

Practice location:
  • Phone: 818-487-0040
  • Fax:
Mailing address:
  • Phone: 717-851-6040
  • Fax: 717-851-3190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD063153L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD063153L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberC143015
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: