Provider Demographics
NPI:1710906557
Name:RANDOLPH, LAURA C (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:C
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2502 E EMPIRE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3738
Mailing Address - Country:US
Mailing Address - Phone:309-664-6222
Mailing Address - Fax:309-664-5006
Practice Address - Street 1:2502 E EMPIRE ST
Practice Address - Street 2:SUITE C
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3738
Practice Address - Country:US
Practice Address - Phone:309-664-6222
Practice Address - Fax:309-664-5006
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-100030208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100030Medicaid
IL097565OtherHEALTH ALLIANCE
ILP00193845OtherRURAL MEDICARE
IL5732066OtherBLUE CROSS BLUE SHIELD
IL686867OtherHEALTH LINK
IL5732066OtherBLUE CROSS BLUE SHIELD
IL036100030Medicaid