Provider Demographics
NPI:1790826220
Name:RANDELL, MARK JAMES (DPT)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:RANDELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49271 S SUPERIOR RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC MINE
Mailing Address - State:MI
Mailing Address - Zip Code:49905-9227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 MACINNES DR STE 201
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-1144
Practice Address - Country:US
Practice Address - Phone:906-483-1888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009981225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist