Provider Demographics
NPI:1164457321
Name:RANDALL, TERRY L (DPT)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:L
Last Name:RANDALL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 MEDPARK DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2734
Mailing Address - Country:US
Mailing Address - Phone:606-679-1761
Mailing Address - Fax:606-678-0971
Practice Address - Street 1:175 MEDPARK DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2734
Practice Address - Country:US
Practice Address - Phone:606-679-1761
Practice Address - Fax:606-678-0971
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT3612255A2300X
KY003180225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY87031803Medicaid
KY000000225912OtherBCBS PROVIDER NUMBER
KY0708601Medicare UPIN