Provider Demographics
NPI:1922092485
Name:RANDOLPH, JAMES KEITH (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:KEITH
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 JEFFERSON AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7101
Mailing Address - Country:US
Mailing Address - Phone:419-251-2673
Mailing Address - Fax:419-251-0916
Practice Address - Street 1:3404 W SYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4467
Practice Address - Country:US
Practice Address - Phone:419-251-1206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2021-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704229515367500000X
OHNA08155367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2541379Medicaid
OH2541379Medicaid
Q36528Medicare UPIN