=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447246509
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANA S AMIRIDZE MD, PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2005
-----------------------------------------------------
Last Update Date | 01/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1251 S HICKORY ST
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32901-3221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-434-3420
-----------------------------------------------------
Fax | 321-434-3423
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 561600
-----------------------------------------------------
City | ROCKLEDGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32956-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-434-4660
-----------------------------------------------------
Fax | 321-259-0635
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | D0060165
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | ME105768
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number | ME105768
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------