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General NPI Number Information
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NPI Number | 1710906557
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Entity Type | Individual
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Provider Name | LAURA C RANDOLPH M.D.
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Gender | Female
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Dates
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Enumeration Date | 07/19/2006
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Last Update Date | 09/12/2013
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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 |
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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 | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 36-100030
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License Number State | IL
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