Provider Demographics
NPI:1497756886
Name:RANDALL, GEORGE RALPH (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:RALPH
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:818 N EMPORIA ST
Mailing Address - Street 2:STE 200
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-3729
Mailing Address - Country:US
Mailing Address - Phone:316-263-0296
Mailing Address - Fax:316-684-3326
Practice Address - Street 1:310 S HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211-2193
Practice Address - Country:US
Practice Address - Phone:316-684-2838
Practice Address - Fax:316-684-3326
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17060207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2745673005OtherCIGNA
KS101370OtherBLUE CROSS BLUE SHIELD
KS101370OtherWAL-MART
KS200811OtherHEALTH PARTNERS OF KS
KS758OtherPREFERRED HEALTH SYSTEMS
KS10084850BOtherFIRST GUARD
4070797OtherAETNA
KS758OtherPREFERRED PLUS OF KS
KSB68568Medicare UPIN
KS101370Medicare ID - Type Unspecified