Healthcare Provider Details

I. General information

NPI: 1518977198
Provider Name (Legal Business Name): IRINA OMARIEVNA SHANIDZE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29275 W 10 MILE RD
FARMINGTON HILLS MI
48336-2817
US

IV. Provider business mailing address

29275 W 10 MILE RD
FARMINGTON HILLS MI
48336-2817
US

V. Phone/Fax

Practice location:
  • Phone: 248-350-2722
  • Fax: 248-350-0154
Mailing address:
  • Phone: 248-350-2722
  • Fax: 248-350-0154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number4301078150
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number4301078150
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: