Provider Demographics
NPI:1144395823
Name:RANDALL, SCOTT A (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:RANDALL
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 1:145 5TH NE
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MI
Mailing Address - Zip Code:49837
Mailing Address - Country:US
Mailing Address - Phone:906-428-3273
Mailing Address - Fax:906-428-1881
Practice Address - Street 1:145 5TH NE
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MI
Practice Address - Zip Code:49837
Practice Address - Country:US
Practice Address - Phone:906-428-3273
Practice Address - Fax:906-428-1881
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072797207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4691697Medicaid
MI1144395823Medicaid
MIM05250048Medicare PIN