Provider Demographics
NPI:1922108422
Name:QUALLS, RANDAL T (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:T
Last Name:QUALLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 802843
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2843
Mailing Address - Country:US
Mailing Address - Phone:417-730-6430
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:1216 DEADRA DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-4669
Practice Address - Country:US
Practice Address - Phone:417-730-5650
Practice Address - Fax:417-730-5655
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103201207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO247943517Medicaid
MO247943517Medicaid
MO1922108422Medicaid
P00232160Medicare PIN
MO1922108422Medicaid
925393123Medicare PIN
MO000050101Medicare PIN