Provider Demographics
NPI:1275362436
Name:NIKOLAISHVILI, MARIAM (MD)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:NIKOLAISHVILI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 SEWARD ST APT K1
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2837
Mailing Address - Country:US
Mailing Address - Phone:773-273-5927
Mailing Address - Fax:
Practice Address - Street 1:355 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3328
Practice Address - Country:US
Practice Address - Phone:773-273-5927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.083820390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program