Provider Demographics
NPI:1417060534
Name:BASHIRUDDIN, IFATH G (MD)
Entity type:Individual
Prefix:
First Name:IFATH
Middle Name:G
Last Name:BASHIRUDDIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BEAVER CREEK CT
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-5497
Mailing Address - Country:US
Mailing Address - Phone:618-239-9500
Mailing Address - Fax:618-239-9555
Practice Address - Street 1:4550 MEMORIAL DR
Practice Address - Street 2:SUITE 360
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5359
Practice Address - Country:US
Practice Address - Phone:618-239-9500
Practice Address - Fax:618-239-9555
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085731207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL390007921OtherRAILROAD MEDICARE
IL036085731Medicaid
P00687628Medicare PIN
IL337510Medicare ID - Type Unspecified
IL036085731Medicaid
211925002Medicare PIN
DG1905Medicare PIN