Provider Demographics
NPI:1831401298
Name:KELLY RANDALL MD INC
Entity type:Organization
Organization Name:KELLY RANDALL MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-332-7311
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-13
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-5927-R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0491052Medicaid
OH200001447OtherRAILROAD MEDICARE
OH000000350042OtherANTHEM CMIC
OH=========1923OtherNEIC
OH000000350042OtherANTHEM CMIC
OH=========1923OtherNEIC
OH200001447OtherRAILROAD MEDICARE