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General NPI Number Information
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NPI Number | 1831401298
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Entity Type | Organization
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Legal Business Name | KELLY RANDALL MD INC
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Dates
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Enumeration Date | 07/13/2010
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Last Update Date | 03/21/2013
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Provider Practice Location Address
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Address Line | 605 3RD AVE SUITE F
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City | FREMONT
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State | OH
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Zip | 43420-3269
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Country | US
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Telephone | 419-332-7311
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Fax | 419-332-8552
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Provider Business Mailing Address
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Address Line | 605 3RD AVE SUITE F
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City | FREMONT
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State | OH
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Zip | 43420-3269
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Country | US
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Telephone | 419-332-7311
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Fax | 419-332-8552
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KELLY RANDALL
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Credential | M.D.
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Telephone | 419-332-7311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 35-04-5927-R
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License Number State | OH
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