Provider Demographics
NPI:1982641668
Name:HEINLE, RANDOLPH M (DO)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:M
Last Name:HEINLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3871 BROADVIEW RD
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44286-9596
Mailing Address - Country:US
Mailing Address - Phone:330-659-4480
Mailing Address - Fax:330-659-4517
Practice Address - Street 1:3871 BROADVIEW RD
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:OH
Practice Address - Zip Code:44286-9596
Practice Address - Country:US
Practice Address - Phone:330-659-4480
Practice Address - Fax:330-659-4517
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34001772207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9934196OtherPTAN-GROUP
OH0015551OtherPTAN
OH1982641668OtherNPI
OHB99624Medicare PIN
OHB99624Medicare UPIN