MEDICARE: MR. SUSHILKUMAR MAHABIRPRASAD TIBREWALA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	036-073571	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	833199720	OTHER	IL	AETNA
3	0010023397	OTHER	IL	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1457366858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SUSHILKUMAR MAHABIRPRASAD TIBREWALA M.D.

Provider Business Mailing Address
First Line	:	24 PINE LAKE DR
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62901-5410
Country	:	US
Telephone Number	:	618-998-8885
Fax Number	:	618-998-8886

Provider Business Practice Location Address
First Line	:	3301 PATRIOT CT
Second Line	:
City	:	HERRIN
State	:	IL
Zip	:	62948-3782
Country	:	US
Telephone Number	:	618-998-8885
Fax Number	:	618-998-8886

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	09/11/2018

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