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General NPI Number Information
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NPI Number | 1750554218
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Entity Type | Individual
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Provider Name | KYLE RANDALL M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/04/2008
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Last Update Date | 01/25/2021
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Provider Practice Location Address
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Address Line | 715 RICHLAND MALL
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City | ONTARIO
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State | OH
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Zip | 44906-3802
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Country | US
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Telephone | 419-709-8645
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Fax |
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Provider Business Mailing Address
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Address Line | 700 N COLUMBUS ST
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City | CRESTLINE
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State | OH
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Zip | 44827-1455
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XX0005X
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Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
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License Number | 35.124114
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License Number State | OH
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