Healthcare Provider Details

I. General information

NPI: 1174501332
Provider Name (Legal Business Name): RANDALL L MULLIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S DEPOT ST
ANNAWAN IL
61234-7768
US

IV. Provider business mailing address

110 S DEPOT ST
ANNAWAN IL
61234-7768
US

V. Phone/Fax

Practice location:
  • Phone: 309-944-5124
  • Fax: 309-721-1407
Mailing address:
  • Phone: 309-944-5124
  • Fax: 309-721-1407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036048491
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: