Basic Information
| Provider Information | |||||||||
| NPI: | 1851355630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDALL | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 MERCHANT STREET | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452463740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135336507 | ||||||||
| FaxNumber: | 5136459767 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 COMPOSITE DRIVE | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454201475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372938419 | ||||||||
| FaxNumber: | 9372931545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 07/22/2015 | ||||||||
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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 | 207Q00000X | 35.059106 R | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0827967 | 05 | OH | MEDICAID |