Provider Demographics
NPI:1447246509
Name:AMIRIDZE, NANA S (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:NANA
Middle Name:S
Last Name:AMIRIDZE
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 561600
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-1600
Mailing Address - Country:US
Mailing Address - Phone:321-434-4660
Mailing Address - Fax:321-259-0635
Practice Address - Street 1:1251 S HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3221
Practice Address - Country:US
Practice Address - Phone:321-434-3420
Practice Address - Fax:321-434-3423
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00601652085R0202X
FLME1057682085R0204X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405376100Medicaid
MD60340002OtherCAREFIRST BCBS
DC0063OtherCAREFIRST BCBS
FL001680100Medicaid
MD60340002OtherCAREFIRST BCBS
MD405376100Medicaid
FL001680100Medicaid
MD865LJ139Medicare PIN
MDI2511Medicare UPIN
MDP00198775Medicare PIN