MEDICARE: DR. RANDAL T QUALLS 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	207Q00000X	Family Medicine Physician	103201	MO

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

General Provider Information

NPI Number	:	1922108422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDAL T QUALLS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 802843
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64180-2843
Country	:	US
Telephone Number	:	417-730-6430
Fax Number	:	417-269-7567

Provider Business Practice Location Address
First Line	:	1216 DEADRA DR
Second Line	:
City	:	LEBANON
State	:	MO
Zip	:	65536-4669
Country	:	US
Telephone Number	:	417-730-5650
Fax Number	:	417-730-5655

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

Provider Enumeration Date	:	09/24/2006
Last Update Date	:	04/07/2023

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