Individual
MR. SUSHILKUMAR MAHABIRPRASAD TIBREWALA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3301 PATRIOT CT, HERRIN, IL 62948-3782
(618) 998-8885
(618) 998-8886
Mailing address
24 PINE LAKE DR, CARBONDALE, IL 62901-5410
(618) 998-8885
(618) 998-8886
Taxonomy
Speciality
Code
Description
License number
State
207RG0100X
Gastroenterology Physician
Primary
036-073571
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0010023397
BLUE CROSS/BLUE SHIELD
IL
05
—
036073571
—
IL
01
—
833199720
AETNA
IL
Enumeration date
07/31/2006
Last updated
09/11/2018
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