MEDICARE: DR. KETEVAN BEREKASHVILI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0204X	Vascular & Interventional Radiology Physician	286750	NY
2	2084N0400X	Neurology Physician	286750	NY
3	2084V0102X	Vascular Neurology Physician	286750	NY

General Provider Information

NPI Number	:	1114284734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KETEVAN BEREKASHVILI MD

Provider Business Mailing Address
First Line	:	211 61 STREET
Second Line	:	APT 1
City	:	BROOKLYN
State	:	NY
Zip	:	11220
Country	:	US
Telephone Number	:	718-630-1270
Fax Number	:	201-387-1036

Provider Business Practice Location Address
First Line	:	211 61ST ST APT 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-3782
Country	:	US
Telephone Number	:	718-630-1270
Fax Number	:	201-387-1036

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2012
Last Update Date	:	03/14/2019

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