Provider Demographics
NPI:1245232693
Name:HALLEY, RANDALL E (DO)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:E
Last Name:HALLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2806 OAK TREE DR
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-9406
Mailing Address - Country:US
Mailing Address - Phone:417-725-8250
Mailing Address - Fax:417-725-8253
Practice Address - Street 1:2101 CORONA RD
Practice Address - Street 2:STE 102
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-2582
Practice Address - Country:US
Practice Address - Phone:573-234-1800
Practice Address - Fax:573-234-1799
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9D75207Q00000X, 207QH0002X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO241991223Medicaid
MO241991231Medicaid
MOCJ9303OtherRR MEDICARE - PRIVATE
MO080184553OtherRAILROAD MEDICARE
MO1245232693Medicaid
P00221221OtherRR MEDICARE DHOS
MOCJ9303OtherRR MEDICARE - PRIVATE
MO080184553OtherRAILROAD MEDICARE
MO000013652Medicare PIN
D41510Medicare UPIN
MO1245232693Medicaid