Basic Information
| Provider Information | |||||||||
| NPI: | 1770580706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCONNIE | ||||||||
| FirstName: | RANDOLPH | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 967 | ||||||||
| Address2: | |||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604770967 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 17850 KEDZIE AVE | ||||||||
| Address2: | 3200 | ||||||||
| City: | HAZEL CREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604292058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087988112 | ||||||||
| FaxNumber: | 7087989016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 036079072 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 2080P0206X | 036-079072 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 036079072 | 05 | IL | MEDICAID |