Provider Demographics
NPI:1659324200
Name:WHITELY, RANDOLPH RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:RICHARD
Last Name:WHITELY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RANDOLPH
Other - Middle Name:NORMAN
Other - Last Name:WHITELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1005 N B ST
Mailing Address - Street 2:
Mailing Address - City:HERINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67449-1600
Mailing Address - Country:US
Mailing Address - Phone:785-258-2100
Mailing Address - Fax:785-258-2104
Practice Address - Street 1:1005 N B ST
Practice Address - Street 2:
Practice Address - City:HERINGTON
Practice Address - State:KS
Practice Address - Zip Code:67449-1600
Practice Address - Country:US
Practice Address - Phone:785-258-2100
Practice Address - Fax:785-258-2104
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-25153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100166280KMedicaid
KS100166280KMedicaid