Individual
DR. MARY KAY RANDOLPH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
36584 W 220TH ST, POLO, MO 64671-8669
(816) 809-7730
Mailing address
36584 W 220TH ST, POLO, MO 64671-8669
(816) 809-7730
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
036-121726
IL
207Q00000X
Family Medicine Physician
04-25049
KS
207Q00000X
Family Medicine Physician
Primary
101542
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
068002402
MEDICARE PTAN
KS
05
—
100175570C
—
KS
Enumeration date
08/15/2006
Last updated
09/19/2023
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