Healthcare Provider Details

I. General information

NPI: 1992328330
Provider Name (Legal Business Name): MARTIN RANDALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 05/07/2023
Certification Date: 05/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13699 E. OLD US HIGHWAY 12
CHLESEA MI
48118-5097
US

IV. Provider business mailing address

13699 E. OLD US HIGHWAY 12
CHLESEA MI
48118
US

V. Phone/Fax

Practice location:
  • Phone: 734-475-4500
  • Fax: 734-475-4507
Mailing address:
  • Phone: 734-475-4500
  • Fax: 734-475-4507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301509245
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: