Healthcare Provider Details

I. General information

NPI: 1215048574
Provider Name (Legal Business Name): SUMIT TIWARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 TERMINAL DR STE 4B
EAST ALTON IL
62024-2296
US

IV. Provider business mailing address

2 TERMINAL DR STE 4B
EAST ALTON IL
62024-2296
US

V. Phone/Fax

Practice location:
  • Phone: 618-216-8127
  • Fax: 618-216-8128
Mailing address:
  • Phone: 618-216-8127
  • Fax: 618-216-8128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036153016
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number12760
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number12760
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: