Provider Demographics
NPI:1982763835
Name:ILG, BORIS A (MD)
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:A
Last Name:ILG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1847 1116 CORNELIA ROAD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621
Mailing Address - Country:US
Mailing Address - Phone:864-224-0028
Mailing Address - Fax:864-225-5067
Practice Address - Street 1:1116 CORNELIA ROAD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621
Practice Address - Country:US
Practice Address - Phone:864-224-0028
Practice Address - Fax:864-225-5067
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21618207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC216180Medicaid
SC216180Medicaid
SCH14986Medicare UPIN