Provider Demographics
NPI:1396854436
Name:SOOLEY, GEORGE RANDALL (DC)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:RANDALL
Last Name:SOOLEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 E FAIRCHILD ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-3140
Mailing Address - Country:US
Mailing Address - Phone:217-431-3290
Mailing Address - Fax:
Practice Address - Street 1:11 E FAIRCHILD ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3140
Practice Address - Country:US
Practice Address - Phone:217-431-3290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008299111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9222843OtherBLUECROSS PROVIDER ID
ILK11279Medicare PIN
IL9222843OtherBLUECROSS PROVIDER ID
ILP00151193Medicare PIN