Provider Demographics
NPI:1952566580
Name:ILLIG, ANDREW JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JOSEPH
Last Name:ILLIG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3544
Mailing Address - Country:US
Mailing Address - Phone:203-325-4087
Mailing Address - Fax:203-359-9941
Practice Address - Street 1:1281 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3544
Practice Address - Country:US
Practice Address - Phone:203-325-4087
Practice Address - Fax:203-359-9941
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0513242081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400080089Medicare PIN