Basic Information
| Provider Information | |||||||||
| NPI: | 1205920659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALISOFF | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | LYLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 355 E ERIE ST FL 14 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606113167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122387800 | ||||||||
| FaxNumber: | 3122387801 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 E ERIE ST FL 14 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606113167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122387800 | ||||||||
| FaxNumber: | 3122387801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 04/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 036-123018 | IL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208VP0014X | 036-123018 | IL | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 2081P2900X | 036-123018 | IL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036123018-1 | 05 | IL | MEDICAID |