Provider Demographics
NPI:1548353964
Name:LILIA B IDANAN PHYSICIAN, PC
Entity type:Organization
Organization Name:LILIA B IDANAN PHYSICIAN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LILIA
Authorized Official - Middle Name:
Authorized Official - Last Name:IDANAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-255-2333
Mailing Address - Street 1:153 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-1103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9715 64TH RD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2250
Practice Address - Country:US
Practice Address - Phone:718-275-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184732207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01922334Medicaid
NY184732POtherHEALTHCARE PARTNERS
NY2591372OtherGHI
NY226AY1OtherEMPIRE BCBS
NY289030201OtherHEALTH PLUS
NY450538OtherAMERIHEALTH
NY0100331OtherAMERICHOICE
NY1112538OtherHEALTH FIRST
NY177179OtherELDERPLAN
NYP2457769OtherOXFORD
NY226AY1OtherEMPIRE BCBS
NYP2457769OtherOXFORD
NY184732POtherHEALTHCARE PARTNERS