Provider Demographics
NPI:1609080969
Name:GURPREET RANDHAWA MD PA
Entity Type:Organization
Organization Name:GURPREET RANDHAWA MD PA
Other - Org Name:RANDHAWA PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEIVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDHAWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-626-5033
Mailing Address - Street 1:1411 W 15TH ST
Mailing Address - Street 2:#202
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901-2285
Mailing Address - Country:US
Mailing Address - Phone:620-626-5033
Mailing Address - Fax:620-624-7881
Practice Address - Street 1:1411 W 15TH ST
Practice Address - Street 2:#202
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2285
Practice Address - Country:US
Practice Address - Phone:620-626-5033
Practice Address - Fax:620-624-7881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0428472208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS103220OtherBCBS
KS100362020BMedicaid
KS110692OtherBCBS GROUP
KS100362020BMedicaid
KS103220OtherBCBS