Healthcare Provider Details

I. General information

NPI: 1073780375
Provider Name (Legal Business Name): RANDALL SCOTT FENNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 W 18TH ST
SIOUX FALLS SD
57105-0401
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 605-328-8700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberRT2213
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number8830
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: