Healthcare Provider Details

I. General information

NPI: 1245219443
Provider Name (Legal Business Name): RANDY EUGENE OLIVER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 W 10TH ST
METROPOLIS IL
62960-2433
US

IV. Provider business mailing address

1203 W 10TH ST
METROPOLIS IL
62960-2433
US

V. Phone/Fax

Practice location:
  • Phone: 618-524-3795
  • Fax: 618-524-3211
Mailing address:
  • Phone: 618-524-3795
  • Fax: 618-524-3211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036066914
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: