Healthcare Provider Details

I. General information

NPI: 1275416463
Provider Name (Legal Business Name): GERONN RANDALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 07/28/2025
Certification Date: 07/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1629 E LOMBARD ST
SPRINGFIELD MO
65802-3326
US

IV. Provider business mailing address

1629 E LOMBARD ST
SPRINGFIELD MO
65802-3326
US

V. Phone/Fax

Practice location:
  • Phone: 440-668-9828
  • Fax:
Mailing address:
  • Phone: 440-668-9828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: