Provider Demographics
NPI:1245219443
Name:OLIVER, RANDY EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:EUGENE
Last Name:OLIVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-2433
Mailing Address - Country:US
Mailing Address - Phone:618-524-3795
Mailing Address - Fax:618-524-3211
Practice Address - Street 1:1203 W 10TH ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2433
Practice Address - Country:US
Practice Address - Phone:618-524-3795
Practice Address - Fax:618-524-3211
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066914207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0006400033OtherBCBS OF ILLINOIS
KY000000042814OtherANTHEM BCBS OF KENTUCKY
080175942OtherRAILROAD MEDICARE
IL1245219443Medicaid
IL036066914Medicaid
IL036066914Medicaid
IL0006400033OtherBCBS OF ILLINOIS
ILL40888Medicare PIN