Provider Demographics
NPI:1609869924
Name:ILNICKIJ, MARYANNE R (MD)
Entity type:Individual
Prefix:DR
First Name:MARYANNE
Middle Name:R
Last Name:ILNICKIJ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WINDFIELD LN
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-9651
Mailing Address - Country:US
Mailing Address - Phone:518-279-4461
Mailing Address - Fax:518-279-3078
Practice Address - Street 1:2 WINDFIELD LN
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-9651
Practice Address - Country:US
Practice Address - Phone:518-279-4461
Practice Address - Fax:518-279-3078
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01305128Medicaid
NY01305128Medicaid
NYRA1542Medicare ID - Type Unspecified