1659324200 NPI number — DR. RANDOLPH RICHARD WHITELY M.D.

Table of content: DR. RANDOLPH RICHARD WHITELY M.D. (NPI 1659324200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659324200 NPI number — DR. RANDOLPH RICHARD WHITELY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITELY
Provider First Name:
RANDOLPH
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHITELY
Provider Other First Name:
RANDOLPH
Provider Other Middle Name:
NORMAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659324200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 N B ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERINGTON
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67449-1600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-258-2100
Provider Business Mailing Address Fax Number:
785-258-2104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 N B ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERINGTON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67449-1600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-258-2100
Provider Business Practice Location Address Fax Number:
785-258-2104
Provider Enumeration Date:
05/17/2006

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: 207Q00000X , with the licence number:  04-25153 , 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: 100166280K , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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