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General NPI Number Information
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NPI Number | 1093493041
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Entity Type | Organization
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Legal Business Name | ILLINOIS RURAL HEALTHCARE
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Dates
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Enumeration Date | 07/10/2023
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Last Update Date | 07/10/2023
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Provider Practice Location Address
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Address Line | 17781 HORNBEAN DR
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City | WILDWOOD
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State | MO
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Zip | 63005-4229
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Country | US
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Telephone | 312-953-5636
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Fax |
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Provider Business Mailing Address
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Address Line | 1003 HAUCK DR
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City | ROLLA
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State | MO
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Zip | 65401-2584
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Country | US
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Telephone | 573-466-2056
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Fax | 573-426-3204
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Authorized Official
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Title or Position | CEO
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Name | SARFARAZ JASDANWALA
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Credential | MD
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Telephone | 31-295-3563
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RA0401X
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Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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