Provider Demographics
NPI:1356332407
Name:CARD, RANDALL ORA (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:ORA
Last Name:CARD
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 1:320 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1645
Mailing Address - Country:US
Mailing Address - Phone:218-546-7000
Mailing Address - Fax:218-545-4456
Practice Address - Street 1:320 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1645
Practice Address - Country:US
Practice Address - Phone:218-546-7000
Practice Address - Fax:218-545-4456
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058040207Q00000X
MN37087207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4255760Medicaid
MI080163119Medicare ID - Type UnspecifiedRAILROAD MEDICARE ID
F81350Medicare UPIN
MI4255760Medicaid