=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831149228
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDALL S. PASS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 07/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1506 S. SIOUX DR
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62959-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-997-5270
-----------------------------------------------------
Fax | 618-997-5029
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 577
-----------------------------------------------------
City | CARTERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62918-0577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-985-8221
-----------------------------------------------------
Fax | 618-985-6860
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 41607
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036-116809
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------