Provider Demographics
NPI:1598734584
Name:RANDALL STREET MEDICAL PC
Entity Type:Organization
Organization Name:RANDALL STREET MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-837-9777
Mailing Address - Street 1:675 W RANDALL ST
Mailing Address - Street 2:
Mailing Address - City:COOPERSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49404-1305
Mailing Address - Country:US
Mailing Address - Phone:616-837-9777
Mailing Address - Fax:616-837-7813
Practice Address - Street 1:675 W RANDALL ST
Practice Address - Street 2:
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-1305
Practice Address - Country:US
Practice Address - Phone:616-837-9777
Practice Address - Fax:616-837-7813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006733261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP57675OtherBLUES HMO'S
MI0027003OtherPRIORITY HEALTH HMO
MI4313667Medicaid
MI005703574OtherBCBSMI
MI233956Medicare Oscar/Certification
MI4313667Medicaid
MIP57675OtherBLUES HMO'S