Provider Demographics
NPI:1356393219
Name:OLIVER, RANDALL LEE (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:LEE
Last Name:OLIVER
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 5249
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47716-5249
Mailing Address - Country:US
Mailing Address - Phone:812-477-7246
Mailing Address - Fax:812-477-7240
Practice Address - Street 1:1101 PROFESSIONAL BLVD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-8016
Practice Address - Country:US
Practice Address - Phone:812-477-7246
Practice Address - Fax:812-477-7240
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029835207Q00000X
IN1029835208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000089152OtherANTHEM FAMILY PRACTICE
IN100180970AMedicaid
IN10643OtherHEALTHSOURCE
IN351865226-00OtherPHN
KY64872484Medicaid
IN659100OtherPRINCIPAL
IN0000000386753OtherANTHEM PAIN MGMT
IN1006173OtherCHAMPUS
IN169425OtherHEALTHLINK
IN000000089152OtherANTHEM FAMILY PRACTICE
IN0000000386753OtherANTHEM PAIN MGMT
IN659100OtherPRINCIPAL