MEDICARE: MEDEA MEDICAL PC

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	207QA0000X	Adolescent Medicine (Family Medicine) Physician	285269	NY

General Provider Information

NPI Number	:	1932699709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDEA MEDICAL PC

Provider Business Mailing Address
First Line	:	6829 SPRINGFIELD BLVD
Second Line	:
City	:	OAKLAND GDNS
State	:	NY
Zip	:	11364-2632
Country	:	US
Telephone Number	:	718-225-3001
Fax Number	:	718-225-3002

Provider Business Practice Location Address
First Line	:	6829 SPRINGFIELD BLVD
Second Line	:
City	:	OAKLAND GDNS
State	:	NY
Zip	:	11364-2632
Country	:	US
Telephone Number	:	718-225-3001
Fax Number	:	718-225-3002

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. OMARI CHUBINIDZE
Credential	:	MD
Telephone Number	:	718-225-3001

Provider Enumeration Date	:	05/16/2018
Last Update Date	:	05/16/2018

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