Healthcare Provider Details

I. General information

NPI: 1730447525
Provider Name (Legal Business Name): JESS T. RANDALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date: 09/30/2020
Reactivation Date: 10/07/2020

III. Provider practice location address

740 S LIMESTONE STE L203
LEXINGTON KY
40536-0001
US

IV. Provider business mailing address

319 S. MANNING BLVD SUITE 203
ALBANY NY
12208
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-6754
  • Fax: 859-323-3499
Mailing address:
  • Phone: 518-489-3292
  • Fax: 518-453-6786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number306608
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number35.151910
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number59406
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: