Provider Demographics
NPI:1205826526
Name:ILIA, HANNA C (MD)
Entity Type:Individual
Prefix:MR
First Name:HANNA
Middle Name:C
Last Name:ILIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37083-1710
Mailing Address - Country:US
Mailing Address - Phone:615-666-6425
Mailing Address - Fax:615-666-3261
Practice Address - Street 1:207 W LOCUST ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:TN
Practice Address - Zip Code:37083-1710
Practice Address - Country:US
Practice Address - Phone:615-666-6425
Practice Address - Fax:615-666-3261
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD30470207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3828728Medicaid
G82303Medicare UPIN
TN3828728Medicaid