Provider Demographics
NPI:1497865018
Name:SOUTHARD, RANDALL J (RPT)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:J
Last Name:SOUTHARD
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 N PINE ST STE A
Mailing Address - Street 2:PO BOX 1539
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-4743
Mailing Address - Country:US
Mailing Address - Phone:620-231-5855
Mailing Address - Fax:620-231-5906
Practice Address - Street 1:107 N PINE ST STE A
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-4743
Practice Address - Country:US
Practice Address - Phone:620-231-5855
Practice Address - Fax:620-231-5906
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-02934225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS140949OtherKS BCBS
KS463291Medicaid
KSP00287507OtherKS MEDICARE RAILROAD
KSQ65677Medicare UPIN
KS141032Medicare PIN