Healthcare Provider Details

I. General information

NPI: 1447283007
Provider Name (Legal Business Name): KETEVAN KOBAIDZE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 10/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE
ATLANTA GA
30308-2208
US

IV. Provider business mailing address

550 PEACHTREE ST NE
ATLANTA GA
30308-2208
US

V. Phone/Fax

Practice location:
  • Phone: 404-686-6730
  • Fax:
Mailing address:
  • Phone: 770-908-9768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number54916
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number054916
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: