MEDICARE: SERGIO ILIC, M.D., PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	A31668	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427175983
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERGIO ILIC, M.D., PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	4910 E CLINTON WAY
Second Line	:	SUITE 101
City	:	FRESNO
State	:	CA
Zip	:	93727-1560
Country	:	US
Telephone Number	:	559-453-5203
Fax Number	:	559-453-3321

Provider Business Practice Location Address
First Line	:	264 CLOVIS AVE
Second Line	:	SUITE 207
City	:	CLOVIS
State	:	CA
Zip	:	93612-1115
Country	:	US
Telephone Number	:	559-324-6504
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SERGIO ILIC
Credential	:	M.D.
Telephone Number	:	559-324-6504

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	08/22/2020

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