Individual
DR. KELLY RANDALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
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
—
000000131064
ANTHEM CMIC-TIFFIN
OH
01
—
000000350046
ANTHEM CMIC-FREMONT
OH
05
—
0491052
—
OH
01
—
200001447
RAILROAD MEDICARE
OH
01
—
341368277-00
WORKERS' COMP
OH
01
—
3413682771923
NEIC
OH
Enumeration date
02/21/2006
Last updated
03/21/2013
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