Healthcare Provider Details

I. General information

NPI: 1174145353
Provider Name (Legal Business Name): RANDY KEEGAN IDLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 STANIFORD ST
BOSTON MA
02114-2517
US

IV. Provider business mailing address

8502 FORT HAMILTON PKWY APT 3B
BROOKLYN NY
11209-4816
US

V. Phone/Fax

Practice location:
  • Phone: 617-903-5000
  • Fax:
Mailing address:
  • Phone: 775-636-0076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1019991
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number325526
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: