Basic Information
| Provider Information | |||||||||
| NPI: | 1861457384 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOME | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9605 GRAND RONDE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RONDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973479712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038792002 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9605 GRAND RONDE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RONDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973479712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038792002 | ||||||||
| FaxNumber: | 5038792015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 11/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD17595 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 034558 | 05 | OR | MEDICAID | 0200572 | 01 | WA | WA LABOR & INDUSTRIES | OTHER |