Provider Demographics
NPI:1245446392
Name:ANDERSON OPHTHALMOLOGY PC
Entity type:Organization
Organization Name:ANDERSON OPHTHALMOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ILG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-224-0028
Mailing Address - Street 1:1116 CORNELIA RD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-3317
Mailing Address - Country:US
Mailing Address - Phone:864-224-0028
Mailing Address - Fax:864-224-2030
Practice Address - Street 1:1116 CORNELIA RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29622
Practice Address - Country:US
Practice Address - Phone:864-224-0028
Practice Address - Fax:864-225-5067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC049557Medicaid
SC0164130001Medicare NSC
SC2414Medicare PIN
SC049557Medicaid