Individual
KERRY RANDOLPH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3525 S NATIONAL AVE, STE 101, SPRINGFIELD, MO 65807-7310
(417) 269-5711
Mailing address
PO BOX 4046, SPRINGFIELD, MO 65808-4046
(417) 269-6262
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
R9C05
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
27694
ANTHEM BLUECROSS
—
Enumeration date
03/28/2007
Last updated
07/08/2007
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