Provider Demographics
NPI:1306939939
Name:BINIAURISHVILI, INESSA G (MD)
Entity type:Individual
Prefix:MRS
First Name:INESSA
Middle Name:G
Last Name:BINIAURISHVILI
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 1:11685-C BUSTLETON AVE.
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-2542
Mailing Address - Country:US
Mailing Address - Phone:215-464-7820
Mailing Address - Fax:215-464-7808
Practice Address - Street 1:11685-C BUSTLETON AVE.
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-2542
Practice Address - Country:US
Practice Address - Phone:215-464-7820
Practice Address - Fax:215-464-7808
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD061863-L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016575930004Medicaid
G55818Medicare UPIN
PA0016575930004Medicaid