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General NPI Number Information
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NPI Number | 1255527727
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Entity Type | Organization
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Legal Business Name | LAURA C. RANDOLPH MD SC
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Dates
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Enumeration Date | 09/19/2007
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Last Update Date | 09/19/2007
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Provider Practice Location Address
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Address Line | 2502 E EMPIRE ST SUITE C
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City | BLOOMINGTON
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State | IL
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Zip | 61704-3738
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Country | US
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Telephone | 309-664-6222
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Fax | 309-664-5006
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Provider Business Mailing Address
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Address Line | 2502 E EMPIRE ST SUITE C
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City | BLOOMINGTON
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State | IL
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Zip | 61704-3738
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Country | US
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Telephone | 309-664-6222
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Fax | 309-664-5006
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | RITA DEMPSEY
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Credential |
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Telephone | 309-664-6222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 36100030
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License Number State | IL
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