Healthcare Provider Details

I. General information

NPI: 1306872320
Provider Name (Legal Business Name): RANDALL PETERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1454 N COUNTY ROAD 2050
CARTHAGE IL
62321-3551
US

IV. Provider business mailing address

1454 N COUNTY ROAD 2050 PO BOX 160
CARTHAGE IL
62321-3551
US

V. Phone/Fax

Practice location:
  • Phone: 217-357-8500
  • Fax:
Mailing address:
  • Phone: 217-357-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number47297
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: