MEDICARE: TAMARA KHARAZISHVILI

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1275924532
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA KHARAZISHVILI

Provider Business Mailing Address
First Line	:	10849 63RD AVE
Second Line	:	APT 1B
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1358
Country	:	US
Telephone Number	:	646-684-9834
Fax Number	:

Provider Business Practice Location Address
First Line	:	10849 63RD AVE
Second Line	:	APT 1B
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1358
Country	:	US
Telephone Number	:	646-684-9834
Fax Number	:

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

Provider Enumeration Date	:	02/09/2015
Last Update Date	:	02/09/2015

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