Provider Demographics
NPI:1699879288
Name:MELANIE ILLICH MD PA
Entity type:Organization
Organization Name:MELANIE ILLICH MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:ILLICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-772-2006
Mailing Address - Street 1:PO BOX 23289
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76702
Mailing Address - Country:US
Mailing Address - Phone:254-772-2006
Mailing Address - Fax:254-772-2011
Practice Address - Street 1:213A OLD HEWITT RD
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712
Practice Address - Country:US
Practice Address - Phone:254-772-2006
Practice Address - Fax:254-772-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ21042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113408204Medicaid
TX157845201Medicaid
TX113408204Medicaid
00445UMedicare ID - Type UnspecifiedGROUP
TX157845201Medicaid