Individual
RANDALL D. MOORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
800 EAST CARPENTER STREET, ROOM 2K64, SPRINGFIELD, IL 62769-0001
(217) 525-5643
(217) 544-2521
Mailing address
800 EAST CARPENTER STREET, ROOM 2K64, SPRINGFIELD, IL 62769-0001
(217) 525-5643
(217) 544-2521
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
041318849
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
041318849
IL LICENSE #
IL
01
—
0841504038
BCBS OF ILLINOIS
IL
01
—
209-005619
IL APN LICENSE #
IL
01
—
371115308
GROUP - TRICARE
IL
01
—
72807
AANA#
IL
Enumeration date
10/13/2005
Last updated
07/08/2007
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