NPIMap

Individual provider Active NPI

Randall S. Pass, MD

  • Family Medicine Physician
  • Marion, IL
National Provider Identifier
1831149228
Registry record updated Jul 7, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
036-116809 Issued in IL
Practice address
1506 S. Sioux Dr
Marion, IL 62959-0000
Phone
(618) 997-5270
Fax
(618) 997-5029
NPI assigned
May 10, 2006
Last updated
Jul 7, 2012By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jul 7, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 41607 WI
Family Medicine Physician 207Q00000X 036-116809 IL Primary

Addresses

Primary practice location

1506 S. Sioux Dr
Marion, IL 62959-0000

Mailing address

PO Box 577
Carterville, IL 62918-0577
Phone (618) 985-8221

Other identifiers 6

IdentifierTypeStateIssuer
036116809MedicaidIL
163392OtherILHEALTH ALLIANCE SHAWNEE HEALTH CARE
10007546OtherILBCBS
CF3444OtherILMEDICARE RAIL ROAD
10032052OtherILBCBS SHAWNEE HEALTH
370966854023MedicaidIL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
036-116809ILMDFamily Medicine Physician
41607WIMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Memorial Management Inc Past Accepting new patients
Shawnee Health Service and Development Corp Family Medicine Past Accepting new patients
Memorial Management Inc Family Medicine Past Accepting new patients
Southern Illinois Medical Care Associates LLC Family Medicine Past Accepting new patients

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147219200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1341619200000",
    "number": "1831149228",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 577",
            "city": "CARTERVILLE",
            "state": "IL",
            "postal_code": "629180577",
            "telephone_number": "618-985-8221",
            "fax_number": "618-985-6860"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1506 S. SIOUX DR",
            "city": "MARION",
            "state": "IL",
            "postal_code": "629590000",
            "telephone_number": "618-997-5270",
            "fax_number": "618-997-5029"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PASS",
        "first_name": "RANDALL",
        "middle_name": "S.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-05-10",
        "last_updated": "2012-07-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WI",
            "license": "41607",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IL",
            "license": "036-116809",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036116809",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTH ALLIANCE SHAWNEE HEALTH CARE",
            "identifier": "163392",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "10007546",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RAIL ROAD",
            "identifier": "CF3444",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS SHAWNEE HEALTH",
            "identifier": "10032052",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "370966854023",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Marion, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 7, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.