Provider Demographics
NPI:1679562532
Name:MOORE, RANDALL D (CRNA)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:D
Last Name:MOORE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 EAST CARPENTER STREET
Mailing Address - Street 2:ROOM 2K64
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62769-0001
Mailing Address - Country:US
Mailing Address - Phone:217-525-5643
Mailing Address - Fax:217-544-2521
Practice Address - Street 1:800 EAST CARPENTER STREET
Practice Address - Street 2:ROOM 2K64
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-0001
Practice Address - Country:US
Practice Address - Phone:217-525-5643
Practice Address - Fax:217-544-2521
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041318849367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041318849OtherIL LICENSE #
IL72807OtherAANA#
IL209-005619OtherIL APN LICENSE #
IL371115308OtherGROUP - TRICARE
IL0841504038OtherBCBS OF ILLINOIS
ILK20078Medicare ID - Type UnspecifiedMEDICARE PART B
ILK20078Medicare ID - Type UnspecifiedMCARERR
IL794510Medicare ID - Type UnspecifiedMEDICARE GROUP #
IL371115308OtherGROUP - TRICARE
IL0841504038OtherBCBS OF ILLINOIS
IL1285290Medicare ID - Type UnspecifiedMEDICARE UMWA GROUP #