Provider Demographics
NPI:1780621961
Name:CALLAHAN, RANDI L (MD)
Entity type:Individual
Prefix:
First Name:RANDI
Middle Name:L
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RANDI
Other - Middle Name:
Other - Last Name:TRACY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-781-4111
Mailing Address - Fax:859-441-5214
Practice Address - Street 1:1360 DOLWICK DR
Practice Address - Street 2:
Practice Address - City:ERLANGER
Practice Address - State:KY
Practice Address - Zip Code:41018-3127
Practice Address - Country:US
Practice Address - Phone:859-781-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64262496Medicaid
OH0101197Medicaid
KYP00839864OtherRAILROAD MEDICARE
KY080092535OtherRAILROAD MEDICARE
KY080092535OtherRAILROAD MEDICARE
KYP00839864OtherRAILROAD MEDICARE
KY008580015Medicare PIN