Healthcare Provider Details

I. General information

NPI: 1477155158
Provider Name (Legal Business Name): MAYA BERDZENISHVILI MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 COMMONWEALTH AVE APT 4
BOSTON MA
02116-2510
US

IV. Provider business mailing address

220 COMMONWEALTH AVE APT 4
BOSTON MA
02116-2510
US

V. Phone/Fax

Practice location:
  • Phone: 617-262-6402
  • Fax: 617-262-6402
Mailing address:
  • Phone: 617-262-6402
  • Fax: 617-262-6402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MAYA BERDZENISHVILI
Title or Position: OWNER
Credential: MD
Phone: 617-262-0462