Provider Demographics
NPI:1992795058
Name:PEREPELITSYN, ILYA (MD)
Entity type:Individual
Prefix:DR
First Name:ILYA
Middle Name:
Last Name:PEREPELITSYN
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 1:2211 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3711
Mailing Address - Country:US
Mailing Address - Phone:612-871-1144
Mailing Address - Fax:612-871-2012
Practice Address - Street 1:2211 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3711
Practice Address - Country:US
Practice Address - Phone:612-871-1144
Practice Address - Fax:612-871-2012
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219565207YX0905X
MN49351207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN305473200Medicaid
MAAA11436OtherHARVARD PILGRIM
MAJ27270OtherBLUE CROSS BLUE SHIELD
WI34756700Medicaid
MN305473200Medicaid
WI34756700Medicaid