Provider Demographics
NPI:1437112117
Name:MIRCHAUDANI, ILA H (MD)
Entity Type:Individual
Prefix:
First Name:ILA
Middle Name:H
Last Name:MIRCHAUDANI
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 1:7600 CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111
Mailing Address - Country:US
Mailing Address - Phone:215-728-2040
Mailing Address - Fax:215-728-2064
Practice Address - Street 1:7600 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111
Practice Address - Country:US
Practice Address - Phone:215-728-2040
Practice Address - Fax:215-728-2064
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041516E207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012255420008Medicaid
PA608151R6GMedicare ID - Type Unspecified
PA0012255420008Medicaid