Provider Demographics
NPI:1396943361
Name:ILANO, EDILBERTO C III (PT)
Entity type:Individual
Prefix:
First Name:EDILBERTO
Middle Name:C
Last Name:ILANO
Suffix:III
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8114 BAXTER AVE APT 1H
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1309
Mailing Address - Country:US
Mailing Address - Phone:646-752-6021
Mailing Address - Fax:718-651-8489
Practice Address - Street 1:8114 BAXTER AVE APT 1H
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1309
Practice Address - Country:US
Practice Address - Phone:646-752-6021
Practice Address - Fax:718-651-8489
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02545260Medicaid
NY02545260Medicaid
NYQ36258Medicare UPIN