Healthcare Provider Details

I. General information

NPI: 1033523501
Provider Name (Legal Business Name): TEAH QVAVADZE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 N RUTLEDGE ST FL 4
SPRINGFIELD IL
62702-6700
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-1622
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-2101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMT207459
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036.166578
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036.166578
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: