Provider Demographics
NPI:1558855155
Name:RANDALL, RACHELLE (DPM)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 FORT ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3942
Mailing Address - Country:US
Mailing Address - Phone:810-987-9871
Mailing Address - Fax:
Practice Address - Street 1:600 FORT ST STE 100
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3942
Practice Address - Country:US
Practice Address - Phone:810-987-9871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901400467213E00000X
MI5951001077213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty