Basic Information
| Provider Information | |||||||||
| NPI: | 1255782082 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMRA | ||||||||
| FirstName: | TSAHI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1239 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629013175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186843156 | ||||||||
| FaxNumber: | 6186841040 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 S 14TH ST | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629483631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189422171 | ||||||||
| FaxNumber: | 6189886166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2016 | ||||||||
| LastUpdateDate: | 01/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036148605 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 036148605 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 214881 | 01 | IL | MEDICARE GROUP PTAN | OTHER |