Provider Demographics
NPI:1255527727
Name:LAURA C. RANDOLPH MD SC
Entity type:Organization
Organization Name:LAURA C. RANDOLPH MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMPSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-664-6222
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36100030261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL097565OtherHEALTH ALLIANCE
IL686867OtherHEALTH LINK
ILP00193845OtherRAILROAD MEDICARE
IL5732066OtherBLUE CROSS BLUE SHIELD
IL686867OtherHEALTH LINK