Provider Demographics
NPI:1750370771
Name:PAGE, RANDELL L (DO)
Entity type:Individual
Prefix:
First Name:RANDELL
Middle Name:L
Last Name:PAGE
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:208-463-3044
Practice Address - Street 1:215 E HAWAII AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6011
Practice Address - Country:US
Practice Address - Phone:208-463-3234
Practice Address - Fax:208-463-3044
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID088207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDS0883OtherBLUE CROSS
ID002365800Medicaid
ID110057530OtherRAILROAD MEDICARE
ID000010006056OtherBLUE SHIELD
IDS0883OtherBLUE CROSS
ID1300907Medicare ID - Type Unspecified