Individual
IFATH G BASHIRUDDIN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
4550 MEMORIAL DR, SUITE 360, BELLEVILLE, IL 62226-5359
(618) 239-9500
(618) 239-9555
Mailing address
7 BEAVER CREEK CT, SAINT CHARLES, MO 63303-5497
(618) 239-9500
(618) 239-9555
Taxonomy
Speciality
Code
Description
License number
State
207RN0300X
Nephrology Physician
Primary
036085731
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036085731
—
IL
01
—
390007921
RAILROAD MEDICARE
IL
Enumeration date
08/15/2006
Last updated
01/31/2012
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