Individual
DR. LAURA C RANDOLPH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
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
208200000X
Plastic Surgery Physician
Primary
36-100030
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036100030
—
IL
01
—
097565
HEALTH ALLIANCE
IL
01
—
5732066
BLUE CROSS BLUE SHIELD
IL
01
—
686867
HEALTH LINK
IL
01
—
P00193845
RURAL MEDICARE
IL
Enumeration date
07/19/2006
Last updated
09/12/2013
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