Provider Demographics
NPI:1245272418
Name:KINSELLA, T RANDALL (MD)
Entity type:Individual
Prefix:DR
First Name:T
Middle Name:RANDALL
Last Name:KINSELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:917 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2203
Mailing Address - Country:US
Mailing Address - Phone:847-295-1220
Mailing Address - Fax:847-295-1227
Practice Address - Street 1:917 SHERWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-2203
Practice Address - Country:US
Practice Address - Phone:847-295-1220
Practice Address - Fax:847-295-1227
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL36069577208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36069577Medicaid
F71627Medicare UPIN