Provider Demographics
NPI:1144280785
Name:YESSENOW, RANDALL SCOTT (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:SCOTT
Last Name:YESSENOW
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:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-0405
Mailing Address - Country:US
Mailing Address - Phone:219-742-0990
Mailing Address - Fax:
Practice Address - Street 1:60 E DELAWARE PL STE 1400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-1806
Practice Address - Country:US
Practice Address - Phone:312-202-9909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039206208200000X
IL036.086614208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1859137007OtherCIGNA PROVIDER NO.
IN4411395OtherAETNA PROVIDER NO.
IN942359OtherUNITED HEALTHCARE NO.
IN88688OtherANTHEM PROVIDER NO.
IN911-08053OtherBC/BS OF IL PROVIDER NO.
IN252040Medicare PIN
IN1859137007OtherCIGNA PROVIDER NO.