Healthcare Provider Details

I. General information

NPI: 1285292383
Provider Name (Legal Business Name): SULEMAN ILYAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

593 EDDY STREET
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 401-457-3336
  • Fax: 401-525-2549
Mailing address:
  • Phone: 401-457-3336
  • Fax: 401-525-2549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT217986
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberLP04789
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: