Provider Demographics
NPI:1972568053
Name:JERNEJCIC, RANDY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:MICHAEL
Last Name:JERNEJCIC
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 1:5450 FRANTZ RD STE 250
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:393 E TOWN ST STE 116
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4799
Practice Address - Country:US
Practice Address - Phone:614-566-9108
Practice Address - Fax:614-566-8737
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000346984OtherBCBS FOR BUCYRUS
OH000000259658OtherBCBS MARION
OH2212055Medicaid
OHP00307843Medicare PIN
OHHO9354Medicare UPIN
OH2212055Medicaid
OH930117502Medicare PIN
JE4017556Medicare PIN