Active NPI
Kerry Randolph, M.D.
- Internal Medicine Physician
- Springfield, MO
National Provider Identifier
1063531390
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Internal Medicine Physician
- License
- R9C05
- Practice address
- 3525 S National Ave
Ste 101
Springfield, MO 65807-7310 - Phone
- (417) 269-5711
- NPI assigned
- Mar 28, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | R9C05 | MO | Primary |
Addresses
Primary practice location
3525 S National Ave
Ste 101
Springfield, MO 65807-7310
Mailing address
PO Box 4046
Springfield, MO 65808-4046
Phone (417) 269-6262
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 27694 | Other | ANTHEM BLUECROSS |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| R9C05 | MO | MD | Internal Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Ozarks Medical Center | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
dba Ozarks Healthcare
- General Acute Care Hospital
- West Plains, MO
- NPI 1831115641
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1175040000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1063531390",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 4046",
"city": "SPRINGFIELD",
"state": "MO",
"postal_code": "658084046",
"telephone_number": "417-269-6262"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3525 S NATIONAL AVE",
"address_2": "STE 101",
"city": "SPRINGFIELD",
"state": "MO",
"postal_code": "658077310",
"telephone_number": "417-269-5711"
}
],
"practiceLocations": [],
"basic": {
"last_name": "RANDOLPH",
"first_name": "KERRY",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-03-28",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": "MO",
"license": "R9C05",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "ANTHEM BLUECROSS",
"identifier": "27694",
"state": null
}
],
"endpoints": [],
"other_names": []
}Other providers in Springfield, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.