Provider Demographics
NPI:1306872320
Name:PETERS, RANDALL (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:PETERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1454 N COUNTY ROAD 2050
Mailing Address - Street 2:PO BOX 160
Mailing Address - City:CARTHAGE
Mailing Address - State:IL
Mailing Address - Zip Code:62321-3551
Mailing Address - Country:US
Mailing Address - Phone:217-357-8500
Mailing Address - Fax:
Practice Address - Street 1:1454 N COUNTY ROAD 2050
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:IL
Practice Address - Zip Code:62321-3551
Practice Address - Country:US
Practice Address - Phone:217-357-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47297208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34596200Medicaid
WI34596200Medicaid
WI008145003Medicare PIN