Healthcare Provider Details

I. General information

NPI: 1124281571
Provider Name (Legal Business Name): ILKO FAMILY MEDICINE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 02/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1687 WOODLANE DR SUITE 102
WOODBURY MN
55125-3045
US

IV. Provider business mailing address

PO BOX 25530
WOODBURY MN
55125-0530
US

V. Phone/Fax

Practice location:
  • Phone: 651-209-6685
  • Fax: 651-209-1680
Mailing address:
  • Phone: 651-209-6685
  • Fax: 651-209-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA RYAN
Title or Position: MANAGER
Credential:
Phone: 815-834-7200