Provider Demographics
NPI:1669400297
Name:RANDALL, STEPHEN HALL (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:HALL
Last Name:RANDALL
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 1:1226 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1155
Mailing Address - Country:US
Mailing Address - Phone:315-478-4185
Mailing Address - Fax:315-478-0840
Practice Address - Street 1:1226 E WATER ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1155
Practice Address - Country:US
Practice Address - Phone:315-478-3468
Practice Address - Fax:315-214-2840
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169344-12085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01262477Medicaid
NY38586DMedicare ID - Type Unspecified
NY01262477Medicaid
38586AMedicare PIN