Healthcare Provider Details

I. General information

NPI: 1972568053
Provider Name (Legal Business Name): RANDY MICHAEL JERNEJCIC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 E TOWN ST STE 116
COLUMBUS OH
43215-4799
US

IV. Provider business mailing address

5450 FRANTZ RD STE 250
DUBLIN OH
43016-4141
US

V. Phone/Fax

Practice location:
  • Phone: 614-566-9108
  • Fax: 614-566-8737
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35075717
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: