Healthcare Provider Details

I. General information

NPI: 1487643029
Provider Name (Legal Business Name): MOHAMMAD F ILYAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 265 WEST & JUNCTION 191 SOUTH SAGE MEMORIAL HOSPITAL
GANADO AZ
86505
US

IV. Provider business mailing address

PO BOX 457 SAGE MEMORIAL HOSPITAL
GANADO AZ
86505-0457
US

V. Phone/Fax

Practice location:
  • Phone: 928-755-4500
  • Fax: 928-755-4659
Mailing address:
  • Phone: 928-755-4500
  • Fax: 928-755-4659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number29895
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: