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General NPI Number Information
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NPI Number | 1174501332
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Entity Type | Individual
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Provider Name | RANDALL L MULLIN MD
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Gender | Male
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Dates
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Enumeration Date | 01/06/2006
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Last Update Date | 01/15/2014
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Provider Practice Location Address
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Address Line | 110 S DEPOT ST
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City | ANNAWAN
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State | IL
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Zip | 61234-7768
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Country | US
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Telephone | 309-944-5124
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Fax | 309-721-1407
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Provider Business Mailing Address
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Address Line | 110 S DEPOT ST
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City | ANNAWAN
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State | IL
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Zip | 61234-7768
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Country | US
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Telephone | 309-944-5124
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Fax | 309-721-1407
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036048491
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License Number State | IL
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