Provider Demographics
NPI:1093493041
Name:ILLINOIS RURAL HEALTHCARE
Entity type:Organization
Organization Name:ILLINOIS RURAL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SARFARAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:JASDANWALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:031-295-3563
Mailing Address - Street 1:1003 HAUCK DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2584
Mailing Address - Country:US
Mailing Address - Phone:573-466-2056
Mailing Address - Fax:573-426-3204
Practice Address - Street 1:17781 HORNBEAN DR
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63005-4229
Practice Address - Country:US
Practice Address - Phone:312-953-5636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty