Provider Demographics
NPI:1801817226
Name:RANDALL, HENRY B (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:B
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 504407
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4407
Mailing Address - Country:US
Mailing Address - Phone:816-932-7940
Mailing Address - Fax:816-932-7957
Practice Address - Street 1:4320 WORNALL RD
Practice Address - Street 2:SUITE 240
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5941
Practice Address - Country:US
Practice Address - Phone:816-932-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010016523204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1801817226Medicaid
MOF68471Medicare UPIN
MOW19000058Medicare PIN