Provider Demographics
NPI:1780682732
Name:COWART, RANDY GENE (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:GENE
Last Name:COWART
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 1:1350 CEDAR CT
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5336
Mailing Address - Country:US
Mailing Address - Phone:618-529-2955
Mailing Address - Fax:618-457-7823
Practice Address - Street 1:1350 CEDAR CT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5336
Practice Address - Country:US
Practice Address - Phone:618-529-2955
Practice Address - Fax:618-457-7823
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-085906207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36-085906Medicaid
ILP00138866Medicare PIN
209287Medicare PIN
ILDB9521Medicare PIN
IL36-085906Medicaid
F56717Medicare UPIN