Provider Demographics
NPI:1114924354
Name:RANDALL S. PRUST MD PC
Entity Type:Organization
Organization Name:RANDALL S. PRUST MD PC
Other - Org Name:RINCON PAIN & SPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:S
Authorized Official - Last Name:PRUST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-731-4450
Mailing Address - Street 1:4747 E CAMP LOWELL DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1256
Mailing Address - Country:US
Mailing Address - Phone:520-322-2560
Mailing Address - Fax:520-731-5541
Practice Address - Street 1:4747 E CAMP LOWELL DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1256
Practice Address - Country:US
Practice Address - Phone:520-731-5540
Practice Address - Fax:520-731-5541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWMBJZMedicare PIN