MEDICARE: RANDALL STREET MEDICAL PC

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	261QR1300X	Rural Health Clinic/Center	5101006733	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P57675	OTHER	MI	BLUES HMO'S
2	0027003	OTHER	MI	PRIORITY HEALTH HMO
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	005703574	OTHER	MI	BCBSMI

General Provider Information

NPI Number	:	1598734584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDALL STREET MEDICAL PC

Provider Business Mailing Address
First Line	:	675 W RANDALL ST
Second Line	:
City	:	COOPERSVILLE
State	:	MI
Zip	:	49404-1305
Country	:	US
Telephone Number	:	616-837-9777
Fax Number	:	616-837-7813

Provider Business Practice Location Address
First Line	:	675 W RANDALL ST
Second Line	:
City	:	COOPERSVILLE
State	:	MI
Zip	:	49404-1305
Country	:	US
Telephone Number	:	616-837-9777
Fax Number	:	616-837-7813

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. ROGER HOLMAN
Credential	:	D.O.
Telephone Number	:	616-837-9777

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/22/2008

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Directions to “RANDALL STREET MEDICAL PC ” Practice Location

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