Healthcare Provider Details

I. General information

NPI: 1457366858
Provider Name (Legal Business Name): SUSHILKUMAR MAHABIRPRASAD TIBREWALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SUSHIL TIBREWALA M.D.

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 PATRIOT CT
HERRIN IL
62948-3782
US

IV. Provider business mailing address

24 PINE LAKE DR
CARBONDALE IL
62901-5410
US

V. Phone/Fax

Practice location:
  • Phone: 618-998-8885
  • Fax: 618-998-8886
Mailing address:
  • Phone: 618-998-8885
  • Fax: 618-998-8886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036-073571
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: