Organization
KELLY RANDALL MD INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KELLY RANDALL M.D. (PRESIDENT)
(419) 332-7311
Entity
Organization
Contact information
Practice address
605 3RD AVE, SUITE F, FREMONT, OH 43420-3269
(419) 332-7311
(419) 332-8552
Mailing address
605 3RD AVE, SUITE F, FREMONT, OH 43420-3269
(419) 332-7311
(419) 332-8552
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
35-04-5927-R
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000350042
ANTHEM CMIC
OH
05
—
0491052
—
OH
01
—
200001447
RAILROAD MEDICARE
OH
Enumeration date
07/13/2010
Last updated
03/21/2013
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