Provider Demographics
NPI:1750507398
Name:RANDALL E HALLEY DO
Entity Type:Organization
Organization Name:RANDALL E HALLEY DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KLIPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-753-9404
Mailing Address - Street 1:PO BOX 1455
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-1455
Mailing Address - Country:US
Mailing Address - Phone:417-753-9404
Mailing Address - Fax:
Practice Address - Street 1:1200 W HALL ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-9103
Practice Address - Country:US
Practice Address - Phone:417-753-9404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9D75207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO505984203Medicaid
MO000013652Medicare ID - Type Unspecified