Healthcare Provider Details

I. General information

NPI: 1598076358
Provider Name (Legal Business Name): HRISTELINA S. ILIEVA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2010
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 WALNUT STREET 2ND FLOOR
PHILADELPHIA PA
19107-3342
US

IV. Provider business mailing address

4400 BROADWAY STE 520
KANSAS CITY MO
64111-3342
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-1234
  • Fax: 215-955-6792
Mailing address:
  • Phone: 816-960-7601
  • Fax: 816-960-7699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2017017634
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberMD469267
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: