Provider Demographics
NPI:1093775405
Name:SOUTHERN ILLINOIS GI SPECIALISTS LLC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS GI SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZAHOOR
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAKHDOOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-549-8006
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-0365
Mailing Address - Country:US
Mailing Address - Phone:618-476-9399
Mailing Address - Fax:618-476-9547
Practice Address - Street 1:1100 W DIANN LN
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5339
Practice Address - Country:US
Practice Address - Phone:618-549-8006
Practice Address - Fax:618-549-8434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094155207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
063398OtherHEALTH ALLIANCE HMO
IL036094155Medicaid
IL03926864OtherBCBS IL
435384OtherHEALTHLINK
IL210478Medicare PIN
063398OtherHEALTH ALLIANCE HMO
IL03926864OtherBCBS IL