Provider Demographics
NPI:1609808781
Name:MITCHEM, RANDALL E (DO)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:E
Last Name:MITCHEM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5301 FARAON ST STE 210A
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3512
Mailing Address - Country:US
Mailing Address - Phone:816-271-1385
Mailing Address - Fax:816-271-1379
Practice Address - Street 1:5301 FARAON ST
Practice Address - Street 2:SUITE 210
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3373
Practice Address - Country:US
Practice Address - Phone:816-271-1385
Practice Address - Fax:816-271-1379
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6J49207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205865009Medicaid
MS2104655OtherAETNA
KS100233020BMedicaid
KS403991OtherBLUE CROSS BLUE SHIELD KS
MO10001363800OtherCHP
MO25862028OtherBLUE CROSS BLUE SHIELD KC
MO10001363800OtherCHP
MOE65003Medicare UPIN
MO7011423Medicare ID - Type Unspecified
KS100233020BMedicaid