MEDICARE: RANDOLPH THOMAS JACKSON M.D.

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	207W00000X	Ophthalmology Physician	46566	MN
2	207W00000X	Ophthalmology Physician	10506	MT
3	207W00000X	Ophthalmology Physician	31896	KS
4	207W00000X	Ophthalmology Physician	2006012805	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00685107	OTHER	KS	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1457310518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDOLPH THOMAS JACKSON M.D.

Provider Business Mailing Address
First Line	:	4801 S CLIFF AVE
Second Line	:	SUITE 100
City	:	INDEPENDENCE
State	:	MO
Zip	:	64055-7015
Country	:	US
Telephone Number	:	816-350-4536
Fax Number	:	816-350-4585

Provider Business Practice Location Address
First Line	:	11010 HASKELL AVE
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66109-8500
Country	:	US
Telephone Number	:	816-478-1230
Fax Number	:	816-350-4166

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

Provider Enumeration Date	:	03/18/2006
Last Update Date	:	05/07/2009

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