Provider Demographics
NPI:1467449827
Name:JENNINGS, RANDALL W (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:W
Last Name:JENNINGS
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 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2045
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4515
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4515
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105293207X00000X
WI43003-020207XX0005X
LAL09261R207XX0005X
ORMD166994207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500677744Medicaid
ORR0000WFBTVOtherGROUP MEDICARE NORTH BEND MEDICAL CENTER
OR1407812365OtherGROUP NPI NORTH BEND MEDICAL CENTER
OR161133OtherGROUP MEDICAID NORTH BEND MEDICAL CENTER
ORP01434156OtherRAILROAD MEDICARE
WI005530345OtherMEDICARE ID, UNSPECIFIED
OR93-0635514OtherGROUP TAX ID NUMBER NORTH BEND MEDICAL CENTER
OR1407812365OtherGROUP NPI NORTH BEND MEDICAL CENTER
F78408Medicare UPIN