Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208100000X | Physical Medicine & Rehabilitation Doctor | 036-123018 | IL |
Y | 2081P2900X | Pain Medicine | 036-123018 | IL |
NPI | 1205920659 |
---|---|
Provider Name | Dr. Randy Lyle Calisoff |
First Address | Chicago, IL 60611-2654 |
Second Address | Chicago, IL 60611-2654 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2006 |
Last Update Date | 28/04/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036123018-1 | (05) | IL |