MEDICARE: RANDALL S. PASS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	41607	WI
2	207Q00000X	Family Medicine Physician	036-116809	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	CF3444	OTHER	IL	MEDICARE RAIL ROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	10007546	OTHER	IL	BCBS
3	163392	OTHER	IL	HEALTH ALLIANCE SHAWNEE HEALTH CARE
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	10032052	OTHER	IL	BCBS SHAWNEE HEALTH

General Provider Information

NPI Number	:	1831149228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDALL S. PASS MD

Provider Business Mailing Address
First Line	:	PO BOX 577
Second Line	:
City	:	CARTERVILLE
State	:	IL
Zip	:	62918-0577
Country	:	US
Telephone Number	:	618-985-8221
Fax Number	:	618-985-6860

Provider Business Practice Location Address
First Line	:	1506 S. SIOUX DR
Second Line	:
City	:	MARION
State	:	IL
Zip	:	62959-0000
Country	:	US
Telephone Number	:	618-997-5270
Fax Number	:	618-997-5029

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	07/07/2012

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Directions to “ RANDALL S. PASS MD” Practice Location

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