Basic Information
| Provider Information | |||||||||
| NPI: | 1154304434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIBLETT | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4567 CROSSROADS PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130883589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152952100 | ||||||||
| FaxNumber: | 3152952125 | ||||||||
| Practice Location | |||||||||
| Address1: | 2209 GENESEE STREET | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135015930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157988171 | ||||||||
| FaxNumber: | 3157343064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 11/30/2011 | ||||||||
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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 | 2085R0202X | 24386 | OK | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 262720 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P000274709 | 01 | OK | RAILROAD MEDICARE | OTHER | 248523231 | 01 | OK | MEDICARE | OTHER | 200057370A | 05 | OK | MEDICAID |