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General NPI Number Information
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NPI Number | 1598734584
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Entity Type | Organization
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Legal Business Name | RANDALL STREET MEDICAL PC
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Dates
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Enumeration Date | 03/14/2006
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Last Update Date | 07/22/2008
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Provider Practice Location Address
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Address Line | 675 W RANDALL ST
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City | COOPERSVILLE
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State | MI
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Zip | 49404-1305
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Country | US
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Telephone | 616-837-9777
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Fax | 616-837-7813
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Provider Business Mailing Address
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Address Line | 675 W RANDALL ST
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City | COOPERSVILLE
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State | MI
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Zip | 49404-1305
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Country | US
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Telephone | 616-837-9777
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Fax | 616-837-7813
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | DR. ROGER HOLMAN
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Credential | D.O.
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Telephone | 616-837-9777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | 5101006733
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License Number State | MI
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