Provider Demographics
NPI:1407084916
Name:KINNARD, RANDY S (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:S
Last Name:KINNARD
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 1:10A MARSHELLEN DR
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-6900
Mailing Address - Country:US
Mailing Address - Phone:843-379-9025
Mailing Address - Fax:304-691-1693
Practice Address - Street 1:10A MARSHELLEN DR
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6900
Practice Address - Country:US
Practice Address - Phone:843-379-9025
Practice Address - Fax:304-691-1693
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83462207R00000X
WV25242207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000495918OtherOH MEDICAID UNISON
OH0068881Medicaid
OH310917085156OtherOH MEDICAID CARESOURCE
WV3810023588Medicaid
OH0068881Medicaid