Healthcare Provider Details

I. General information

NPI: 1790945103
Provider Name (Legal Business Name): OB GYN CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 N GREEN MOUNT RD SUITE 107
O FALLON IL
62269-1953
US

IV. Provider business mailing address

1512 N GREEN MOUNT RD SUITE 107
O FALLON IL
62269-1953
US

V. Phone/Fax

Practice location:
  • Phone: 618-628-1717
  • Fax: 618-628-1789
Mailing address:
  • Phone: 618-628-1717
  • Fax: 618-628-1789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036097979
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036097979
License Number StateIL

VIII. Authorized Official

Name: DR. BRADLEY J TISSIER
Title or Position: MEMBER
Credential: MD
Phone: 618-628-1717