Healthcare Provider Details

I. General information

NPI: 1942704507
Provider Name (Legal Business Name): SAMUEL JOHN RANDALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 05/08/2025
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WEST SIDE CLINIC 1735 MADISON ROAD
BELOIT WI
53511-3216
US

IV. Provider business mailing address

WEST SIDE CLINIC 1735 MADISON ROAD
BELOIT WI
53511-3216
US

V. Phone/Fax

Practice location:
  • Phone: 608-363-7510
  • Fax: 608-363-7528
Mailing address:
  • Phone: 608-363-7510
  • Fax: 608-363-7528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number85626-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-156701
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: