MEDICARE: MARK STEVEN RANDALL PSYD HSPP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TH0100X	Health Service Psychologist	20041703A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	680016092	OTHER	IN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538161351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK STEVEN RANDALL PSYD HSPP

Provider Business Mailing Address
First Line	:	8180 CLEARVISTA PARKWAY
Second Line	:	SUITE 230 ATTN SHERRY MUELLER
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-4649
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8075 NORTH SHADELAND AVENUE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-2693
Country	:	US
Telephone Number	:	317-621-8000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	03/10/2011

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