1326133034 NPI number — ELIAS A ILIADIS MD

Table of content: ELIAS A ILIADIS MD (NPI 1326133034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326133034 NPI number — ELIAS A ILIADIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ILIADIS
Provider First Name:
ELIAS
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326133034
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 COOPER PLZ
Provider Second Line Business Mailing Address:
SUITE 502
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08103-1438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-968-7433
Provider Business Mailing Address Fax Number:
856-968-8499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 CENTENNIAL BLVD
Provider Second Line Business Practice Location Address:
BUILDING 2 SUITE 202
Provider Business Practice Location Address City Name:
VOORHEES
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08043-4637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-325-6700
Provider Business Practice Location Address Fax Number:
856-325-6702
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  MA074027 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1172653 . This is a "HORISON NJ HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8856508 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2117895000 . This is a "AMERIHEALTH, KEYSTONE, IBC" identifier . This identifiers is of the category "OTHER".




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