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General NPI Number Information
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NPI Number | 1285854240
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Entity Type | Organization
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Legal Business Name | RANDOM LAKE MEDICAL CENTER LLC
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Dates
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Enumeration Date | 05/01/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | N639 SILVER CREEK CASCADE ROAD
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City | RANDOM LAKE
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State | WI
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Zip | 53075
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Country | US
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Telephone | 920-994-9999
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Fax | 920-994-9998
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Provider Business Mailing Address
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Address Line | PO BOX 246 N639 SILVER CREEK CASCADE RD
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City | RANDOM LAKE
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State | WI
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Zip | 53075
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Country | US
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Telephone | 920-994-9999
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Fax | 920-994-9998
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Authorized Official
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Title or Position | OWNER
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Name | DR. BARBARA A WEBER
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Credential | MD
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Telephone | 920-994-9999
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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 | 39774
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License Number State | WI
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