Provider Demographics
NPI:1386744514
Name:PATRICIO A. ILABACA, MD, PC
Entity type:Organization
Organization Name:PATRICIO A. ILABACA, MD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:ILABACA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-683-6161
Mailing Address - Street 1:6027 WALNUT GROVE RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2145
Mailing Address - Country:US
Mailing Address - Phone:901-683-6161
Mailing Address - Fax:901-683-7998
Practice Address - Street 1:6027 WALNUT GROVE RD
Practice Address - Street 2:SUITE 114
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2145
Practice Address - Country:US
Practice Address - Phone:901-683-6161
Practice Address - Fax:901-683-7998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN95822086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3171424Medicaid
AR09015252Medicaid
B59354Medicare UPIN
TN3171424Medicare ID - Type Unspecified