Basic Information
| Provider Information | |||||||||
| NPI: | 1508803081 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ILADA | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793513 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 PROVIDENT DR STE C | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465803255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742678728 | ||||||||
| FaxNumber: | 5742693470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 01054010A | IN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200326000 | 05 | IN | MEDICAID |