Provider Demographics
NPI:1790723690
Name:RANDALL J SLICKERS, M.D., P.C.
Entity Type:Organization
Organization Name:RANDALL J SLICKERS, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SLICKERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-734-3226
Mailing Address - Street 1:1235 FILER AVE E
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4118
Mailing Address - Country:US
Mailing Address - Phone:208-734-3226
Mailing Address - Fax:208-734-3675
Practice Address - Street 1:1235 FILER AVE E
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4118
Practice Address - Country:US
Practice Address - Phone:208-734-3226
Practice Address - Fax:208-734-3675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID080105158OtherRR MEDICARE
ID003957900Medicaid
ID1109437Medicare ID - Type UnspecifiedMEDICARE NUMBER
ID003957900Medicaid