Provider Demographics
NPI:1790945103
Name:OB GYN CARE LLC
Entity Type:Organization
Organization Name:OB GYN CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TISSIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-628-1717
Mailing Address - Street 1:1512 N GREEN MOUNT RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1953
Mailing Address - Country:US
Mailing Address - Phone:618-628-1717
Mailing Address - Fax:618-628-1789
Practice Address - Street 1:1512 N GREEN MOUNT RD
Practice Address - Street 2:SUITE 107
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1953
Practice Address - Country:US
Practice Address - Phone:618-628-1717
Practice Address - Fax:618-628-1789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097979207V00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty