Healthcare Provider Details

I. General information

NPI: 1235907668
Provider Name (Legal Business Name): ILANT MEDICAL GROUP KS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2023
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 5TH AVE APT 12D
NEW YORK NY
10029-7810
US

IV. Provider business mailing address

2093 PHILADELPHIA PIKE # 4289
CLAYMONT DE
19703-2424
US

V. Phone/Fax

Practice location:
  • Phone: 201-308-3903
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESS MUSE
Title or Position: COO
Credential:
Phone: 201-308-3903