Provider Demographics
NPI:1295880664
Name:ST JOHN, RANDY HOWARD (PT)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:HOWARD
Last Name:ST JOHN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7125 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-4943
Mailing Address - Country:US
Mailing Address - Phone:269-492-6575
Mailing Address - Fax:269-492-6577
Practice Address - Street 1:7125 STADIUM DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-4943
Practice Address - Country:US
Practice Address - Phone:269-492-6575
Practice Address - Fax:269-492-6577
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP40960001Medicare PIN