MEDICARE: MARTHA HERNANDEZ-ILLAS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RR0500X	Rheumatology Physician	ME 87694	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00215148	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	01605	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1972517464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA HERNANDEZ-ILLAS MD

Provider Business Mailing Address
First Line	:	10873 NW 73 TERR
Second Line	:
City	:	DORAL
State	:	FL
Zip	:	33178
Country	:	US
Telephone Number	:	305-594-5793
Fax Number	:

Provider Business Practice Location Address
First Line	:	5333 N DIXIE HWY
Second Line	:	SUITE 110
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33334
Country	:	US
Telephone Number	:	954-229-7030
Fax Number	:	954-229-0963

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	07/08/2007

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Directions to “ MARTHA HERNANDEZ-ILLAS MD” Practice Location

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