Provider Demographics
NPI:1972575587
Name:ILYASOV, ANDREY ALEXANDROVICH (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREY
Middle Name:ALEXANDROVICH
Last Name:ILYASOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1215
Mailing Address - Street 2:ATTN CLINIC BILLING OFFICE
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67905-1215
Mailing Address - Country:US
Mailing Address - Phone:620-629-6638
Mailing Address - Fax:620-629-6684
Practice Address - Street 1:315 W 15TH ST
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2455
Practice Address - Country:US
Practice Address - Phone:620-629-6477
Practice Address - Fax:620-629-6651
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34051207R00000X
NC200501714207R00000X
KS04-37011208M00000X
AL35106208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00435714OtherRAILROAD MEDICARE
NC5902572Medicaid
OK200554510AMedicaid
KS201122270AMedicaid
NC2049089Medicare PIN
KS201122270AMedicaid
NC5902572Medicaid