1497865018 NPI number — RANDALL J SOUTHARD RPT

Table of content: RANDALL J SOUTHARD RPT (NPI 1497865018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497865018 NPI number — RANDALL J SOUTHARD RPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUTHARD
Provider First Name:
RANDALL
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497865018
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 N PINE ST STE A
Provider Second Line Business Mailing Address:
PO BOX 1539
Provider Business Mailing Address City Name:
PITTSBURG
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66762-4743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-231-5855
Provider Business Mailing Address Fax Number:
620-231-5906

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 N PINE ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PITTSBURG
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66762-4743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-231-5855
Provider Business Practice Location Address Fax Number:
620-231-5906
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  11-02934 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 140949 . This is a "KS BCBS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 463291 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00287507 . This is a "KS MEDICARE RAILROAD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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