Provider Demographics
NPI:1083962229
Name:RANDOLPH, ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 E HURON ST STE 16-738
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2908
Mailing Address - Country:US
Mailing Address - Phone:847-234-5600
Mailing Address - Fax:847-535-7203
Practice Address - Street 1:251 E HURON ST.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-926-5140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004395363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical