1831149228 NPI number — RANDALL S. PASS MD

Table of content: RANDALL S. PASS MD (NPI 1831149228)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831149228 NPI number — RANDALL S. PASS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PASS
Provider First Name:
RANDALL
Provider Middle Name:
S.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831149228
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 577
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARTERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62918-0577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-985-8221
Provider Business Mailing Address Fax Number:
618-985-6860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1506 S. SIOUX DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62959-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-997-5270
Provider Business Practice Location Address Fax Number:
618-997-5029
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  41607 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 036-116809 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 370966854023 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10007546 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 163392 . This is a "HEALTH ALLIANCE SHAWNEE HEALTH CARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CF3444 . This is a "MEDICARE RAIL ROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036116809 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10032052 . This is a "BCBS SHAWNEE HEALTH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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