Healthcare Provider Details

I. General information

NPI: 1497756886
Provider Name (Legal Business Name): GEORGE RALPH RANDALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S HILLSIDE ST
WICHITA KS
67211-2193
US

IV. Provider business mailing address

818 N EMPORIA ST STE 200
WICHITA KS
67214-3729
US

V. Phone/Fax

Practice location:
  • Phone: 316-684-2838
  • Fax: 316-684-3326
Mailing address:
  • Phone: 316-263-0296
  • Fax: 316-684-3326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number17060
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: