Basic Information
Provider Information | |||||||||
NPI: | 1720030646 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLIAMS | ||||||||
FirstName: | RANDALL | ||||||||
MiddleName: | EARL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1919 S HIGHLAND AVE | ||||||||
Address2: | SUITE B202 ATTN JAN LEWIS | ||||||||
City: | LOMBARD | ||||||||
State: | IL | ||||||||
PostalCode: | 601486153 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6302681102 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 27750 W HIGHWAY 22 | ||||||||
Address2: | SUITE 240 | ||||||||
City: | BARRINGTON | ||||||||
State: | IL | ||||||||
PostalCode: | 600102379 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8478291600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 07/18/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 036091021 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 036091021 | 05 | IL |   | MEDICAID | P00166673 | 01 |   | RAILROAD MEDICARE | OTHER |