Healthcare Provider Details

I. General information

NPI: 1760739908
Provider Name (Legal Business Name): CHUBINIDZEMD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 OLD TAYLOR TRL
GOSHEN KY
40026-9727
US

IV. Provider business mailing address

1306 OLD TAYLOR TRL
GOSHEN KY
40026-9727
US

V. Phone/Fax

Practice location:
  • Phone: 502-244-5252
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. OMARI CHUBINIDZE
Title or Position: OWNER
Credential:
Phone: 502-244-5252