Provider Demographics
NPI:1962655167
Name:ILYA BADALOV PHYSICIAN PC
Entity Type:Organization
Organization Name:ILYA BADALOV PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BADALOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-847-9329
Mailing Address - Street 1:13511 78TH DR
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3235
Mailing Address - Country:US
Mailing Address - Phone:718-847-9329
Mailing Address - Fax:
Practice Address - Street 1:13511 78TH DR
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-3235
Practice Address - Country:US
Practice Address - Phone:718-847-9329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty