Basic Information
| Provider Information | |||||||||
| NPI: | 1669524096 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHUBINIDZE | ||||||||
| FirstName: | OMARI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E CHESTNUT ST STE 303 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026295552 | ||||||||
| FaxNumber: | 5026293132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 05/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 41262 | KY | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 41262 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 098045 | 01 | NCMA/SIHO | OTHER | 3704051000 | 01 | KY | PASSPORT ADVANTAGE- NORTON INPATIENT SPECIALISTS | OTHER | 50023118 | 01 | KY | PASSPORT- NORTON INPATIENT SPECIALISTS | OTHER | P00434866 | 01 | KY | RAILROAD MEDICARE - KY | OTHER | 000000522775 | 01 | ANTHEM - NICC | OTHER | 090920 | 01 | SIHO - NICC | OTHER |