Basic Information
| Provider Information | |||||||||
| NPI: | 1144395823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDALL | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 5TH NE | ||||||||
| Address2: | |||||||||
| City: | GLADSTONE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064283273 | ||||||||
| FaxNumber: | 9064281881 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 5TH NE | ||||||||
| Address2: | |||||||||
| City: | GLADSTONE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064283273 | ||||||||
| FaxNumber: | 9064281881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301072797 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4691697 | 05 | MI | MEDICAID | 1144395823 | 05 | MI | MEDICAID |