Provider Demographics
NPI:1194703991
Name:ILSLEY, JEFFREY EATON (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:EATON
Last Name:ILSLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0002
Mailing Address - Country:US
Mailing Address - Phone:715-838-5222
Mailing Address - Fax:
Practice Address - Street 1:2321 STOUT RD
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-7003
Practice Address - Country:US
Practice Address - Phone:715-235-5531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23938207P00000X
SCLL3916207Q00000X
WI65669207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00024951OtherMEDICARE RR ID#
SCLL3916Medicaid
SCH831463410Medicare PIN
SCP00024951OtherMEDICARE RR ID#
SCLL3916Medicaid