Basic Information
| Provider Information | |||||||||
| NPI: | 1063439917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JERNIGAN | ||||||||
| FirstName: | RANDAL | ||||||||
| MiddleName: | FORD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5471 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802175471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668987136 | ||||||||
| FaxNumber: | 6169759824 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 THREE SPRINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813018296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707642100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 23756 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | K5532 | 05 | NM | MEDICAID | 76738787 | 05 | CO | MEDICAID |