Provider Demographics
NPI:1609914183
Name:GASTROENTEROLOGY CARE OF SOUTHERN ILLINOIS, LLC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY CARE OF SOUTHERN ILLINOIS, LLC
Other - Org Name:SUSHILKUMAR TIBREWALA, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SUSHILKUNAR
Authorized Official - Middle Name:MAHABIRPRASAD
Authorized Official - Last Name:TIBREWALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-998-8885
Mailing Address - Street 1:24 PINE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5410
Mailing Address - Country:US
Mailing Address - Phone:618-529-3308
Mailing Address - Fax:618-998-8886
Practice Address - Street 1:3301 PATRIOT CT
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3782
Practice Address - Country:US
Practice Address - Phone:618-998-8885
Practice Address - Fax:618-998-8886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-04
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-073571207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0010023397OtherBCBS OF IL
IL036073571Medicaid
IL173109OtherHEALTHLINK PPO
IL046565OtherHEALTH ALLIANCE
IL833199720OtherAETNA