Provider Demographics
NPI:1194165308
Name:ILYA SABSOVICH MD INC A MEDICAL CORPORATION
Entity type:Organization
Organization Name:ILYA SABSOVICH MD INC A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SABSOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-580-0939
Mailing Address - Street 1:13290 LENNOX WAY
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-3542
Mailing Address - Country:US
Mailing Address - Phone:650-580-0939
Mailing Address - Fax:
Practice Address - Street 1:6140 CAMINO VERDE DR
Practice Address - Street 2:SUITE L
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1401
Practice Address - Country:US
Practice Address - Phone:650-580-0939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115064207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty