Provider Demographics
NPI:1831149228
Name:PASS, RANDALL S (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:S
Last Name:PASS
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:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:618-985-6860
Practice Address - Street 1:1506 S. SIOUX DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-0000
Practice Address - Country:US
Practice Address - Phone:618-997-5270
Practice Address - Fax:618-997-5029
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41607207Q00000X
IL036-116809207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370966854023Medicaid
IL10007546OtherBCBS
IL163392OtherHEALTH ALLIANCE SHAWNEE HEALTH CARE
ILCF3444OtherMEDICARE RAIL ROAD
IL036116809Medicaid
IL10032052OtherBCBS SHAWNEE HEALTH
ILK47726Medicare PIN
ILK44551Medicare PIN
IL163392OtherHEALTH ALLIANCE SHAWNEE HEALTH CARE
IL036116809Medicaid
IL370966854023Medicaid