MEDICARE: SHALVA V KAKABADZE 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	207Q00000X	Family Medicine Physician	35079515	OH
2	207Q00000X	Family Medicine Physician	MD442814	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962465427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHALVA V KAKABADZE MD

Provider Business Mailing Address
First Line	:	PO BOX 447
Second Line	:
City	:	DU BOIS
State	:	PA
Zip	:	15801-0447
Country	:	US
Telephone Number	:	814-653-8222
Fax Number	:	814-653-9305

Provider Business Practice Location Address
First Line	:	5 N 3RD ST
Second Line	:
City	:	REYNOLDSVILLE
State	:	PA
Zip	:	15851-0907
Country	:	US
Telephone Number	:	814-653-8222
Fax Number	:	814-653-9305

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

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	06/10/2011

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Directions to “ SHALVA V KAKABADZE MD” Practice Location

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