MEDICARE: RANDALL E HALLEY DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	R9D75	MO
2	207QH0002X	Hospice and Palliative Medicine (Family Medicine) Physician	R9D75	MO
3	207QG0300X	Geriatric Medicine (Family Medicine) Physician	R9D75	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	CJ9303	OTHER	MO	RR MEDICARE - PRIVATE
4	080184553	OTHER	MO	RAILROAD MEDICARE
6	P00221221	OTHER		RR MEDICARE DHOS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245232693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDALL E HALLEY DO

Provider Business Mailing Address
First Line	:	2806 OAK TREE DR
Second Line	:
City	:	NIXA
State	:	MO
Zip	:	65714-9406
Country	:	US
Telephone Number	:	417-725-8250
Fax Number	:	417-725-8253

Provider Business Practice Location Address
First Line	:	2101 CORONA RD
Second Line	:	STE 102
City	:	COLUMBIA
State	:	MO
Zip	:	65203-2582
Country	:	US
Telephone Number	:	573-234-1800
Fax Number	:	573-234-1799

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	10/28/2019

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Directions to “ RANDALL E HALLEY DO” Practice Location

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