Healthcare Provider Details

I. General information

NPI: 1154396364
Provider Name (Legal Business Name): KYLE ROBERT RANDALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 11/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2911 KNAPP ST NE SUITE A
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

2911 KNAPP ST NE SUITE A
GRAND RAPIDS MI
49525
US

V. Phone/Fax

Practice location:
  • Phone: 616-451-9925
  • Fax: 616-328-5380
Mailing address:
  • Phone: 616-451-9925
  • Fax: 616-328-5380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4301061642
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: