Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 2020019849 | MO |
N | 111NI0900X | Internist | 2020019849 | MO |
NPI | 1003336785 |
---|---|
Provider Name | Dr. Randy Olivier Laine |
First Address | Saint Louis, MO 63110-1010 |
Second Address | Saint Louis, MO 63110-1003 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2017 |
Last Update Date | 12/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200061294 | (05) | MO |