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General NPI Number Information
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NPI Number | 1609914183
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Entity Type | Organization
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Legal Business Name | GASTROENTEROLOGY CARE OF SOUTHERN ILLINOIS, LLC
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Dates
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Enumeration Date | 02/04/2007
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Last Update Date | 07/04/2025
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Provider Practice Location Address
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Address Line | 3301 PATRIOT CT
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City | HERRIN
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State | IL
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Zip | 62948-3782
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Country | US
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Telephone | 618-998-8885
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Fax | 618-998-8886
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Provider Business Mailing Address
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Address Line | 24 PINE LAKE DR
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City | CARBONDALE
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State | IL
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Zip | 62901-5410
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Country | US
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Telephone | 618-534-1935
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Fax | 618-998-8886
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. SUSHILKUNAR MAHABIRPRASAD TIBREWALA
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Credential | M.D.
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Telephone | 618-998-8885
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 036-073571
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License Number State | IL
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