Basic Information
| Provider Information | |||||||||
| NPI: | 1669430955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LORENZ | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 623 SOUTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088822011 | ||||||||
| FaxNumber: | 2088831853 | ||||||||
| Practice Location | |||||||||
| Address1: | 623 SOUTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088822011 | ||||||||
| FaxNumber: | 2088831853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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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 | 207R00000X | 34153 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME83125 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | G31181 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD11024 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 946345 | 05 | AZ | MEDICAID |