Provider Demographics
NPI:1982679171
Name:RANDALL, KELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:605 3RD AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-3269
Mailing Address - Country:US
Mailing Address - Phone:419-332-7311
Mailing Address - Fax:419-332-8552
Practice Address - Street 1:605 3RD AVE
Practice Address - Street 2:SUITE F
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-3269
Practice Address - Country:US
Practice Address - Phone:419-332-7311
Practice Address - Fax:419-332-8552
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-5927-R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3413682771923OtherNEIC
OH200001447OtherRAILROAD MEDICARE
OH0491052Medicaid
OH341368277-00OtherWORKERS' COMP
OH000000131064OtherANTHEM CMIC-TIFFIN
OH000000350046OtherANTHEM CMIC-FREMONT
OHRA0511931Medicare PIN
OH000000131064OtherANTHEM CMIC-TIFFIN