1700802295 NPI number — DR. RANDALL AARON GOLDSTEIN DO

Table of content: DR. RANDALL AARON GOLDSTEIN DO (NPI 1700802295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700802295 NPI number — DR. RANDALL AARON GOLDSTEIN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDSTEIN
Provider First Name:
RANDALL
Provider Middle Name:
AARON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOLDSTEIN
Provider Other First Name:
RANDALL
Provider Other Middle Name:
AARON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1700802295
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6301 N LUCERNE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64151-3105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-569-1802
Provider Business Mailing Address Fax Number:
816-569-1882

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6301 N LUCERNE AVE
Provider Second Line Business Practice Location Address:
MOSAIC LIFE CARE AT BURLINGTON CREEK
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64151-3105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-387-7673
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2006

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: 208000000X , with the licence number:  29058 , 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: 1700802295 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".