Organization
LAURA C. RANDOLPH MD SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RITA DEMPSEY (OFFICE MANAGER)
(309) 664-6222
Entity
Organization
Contact information
Practice address
2502 E EMPIRE ST, SUITE C, BLOOMINGTON, IL 61704-3738
(309) 664-6222
(309) 664-5006
Mailing address
2502 E EMPIRE ST, SUITE C, BLOOMINGTON, IL 61704-3738
(309) 664-6222
(309) 664-5006
Taxonomy
Speciality
Code
Description
License number
State
261QM2500X
Medical Specialty Clinic/Center
Primary
36100030
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
097565
HEALTH ALLIANCE
IL
01
—
5732066
BLUE CROSS BLUE SHIELD
IL
01
—
686867
HEALTH LINK
IL
01
—
P00193845
RAILROAD MEDICARE
IL
Enumeration date
09/19/2007
Last updated
09/19/2007
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