Provider Demographics
NPI:1972837094
Name:RANDELL R RAY PC
Entity Type:Organization
Organization Name:RANDELL R RAY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDELL
Authorized Official - Middle Name:R
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:817-526-5558
Mailing Address - Street 1:1420 AIRPORT FWY STE H
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-6778
Mailing Address - Country:US
Mailing Address - Phone:817-283-2001
Mailing Address - Fax:817-283-0993
Practice Address - Street 1:1616 W HENDERSON ST
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4123
Practice Address - Country:US
Practice Address - Phone:817-526-5558
Practice Address - Fax:817-526-5825
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RANDELL R RAY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-22
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2873TG261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0014FGOtherBLUE CROSS BLUE SHIELD OF TEXAS
TX0014FGOtherBLUE CROSS BLUE SHIELD OF TEXAS
TX00E54EMedicare PIN