Healthcare Provider Details

I. General information

NPI: 1215225552
Provider Name (Legal Business Name): NINA BALANCHIVADZE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NINO BALANCHIVADZE

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6251 E VIRGINIA BEACH BLVD STE 200
NORFOLK VA
23502-2800
US

IV. Provider business mailing address

6350 CENTER DR STE 200
NORFOLK VA
23502-4107
US

V. Phone/Fax

Practice location:
  • Phone: 757-466-8683
  • Fax:
Mailing address:
  • Phone: 757-905-5558
  • Fax: 757-213-5762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36560
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301117273
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number0101274592
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: