Provider Demographics
NPI:1124006853
Name:RANDLE, MICHAEL T (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:RANDLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 16TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-5114
Mailing Address - Country:US
Mailing Address - Phone:970-350-2438
Mailing Address - Fax:970-350-2473
Practice Address - Street 1:1900 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5114
Practice Address - Country:US
Practice Address - Phone:970-350-2438
Practice Address - Fax:970-350-2473
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39374207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50483579Medicaid
COP00944796OtherMEDICARE RAILROAD CARRIER PTAN
COCO40998Medicare PIN
COP00944796OtherMEDICARE RAILROAD CARRIER PTAN
COCOA102155Medicare PIN
COE46856Medicare UPIN