Basic Information
| Provider Information | |||||||||
| NPI: | 1295799906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDHAWA | ||||||||
| FirstName: | RANJIV RANDALL | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2555 S MARTIN LUTHER KING JR DRIVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128087201 | ||||||||
| FaxNumber: | 3128425897 | ||||||||
| Practice Location | |||||||||
| Address1: | 2320 E 93RD ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606173909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739675805 | ||||||||
| FaxNumber: | 7739675808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-133007 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD00045355 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8431157 | 05 | WA | MEDICAID |