Randall Street Medical PC
Organization Active NPI Rural Health Clinic/Center · Coopersville, MI
NPI 1598734584 · NPPES record last updated Jul 22, 2008
Key facts
- NPI
- 1598734584
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- License
- 5101006733 (MI)
- Legal business name
- RANDALL STREET MEDICAL PC
- Practice address
- 675 W Randall St
Coopersville, MI 49404-1305 - Phone
- (616) 837-9777
- Fax
- (616) 837-7813
- NPI assigned
- Mar 14, 2006
- Organization subpart
- No
Authorized official
- Name
- Dr. Roger Holman, D.O.
- Title
- Owner/Physician
- Phone
- (616) 837-9777
Owners & managing parties with NPI records 1
-
Roger Holman, DO
Practitioners 6
-
Leah Boeve, FNP
-
Roger Holman, DO
-
Heidi Jo Parcher, AGPCNP-BC
-
Anthony James Hoholik, PA-C
-
Carl E Piersma, P.A.-C.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 23D0379159 | Randall Street Medical PC | Provider-performed microscopy | Mar 3, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MI
Rural health clinic certification: CCN 233956
- Legal name
- RANDALL STREET MEDICAL, P.C.
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Oct 10, 2002
- Last certification
- Jun 12, 2024
- Ownership / control type
- 2A
- Organization structure
- Corporation · Proprietary
- Incorporated
- May 14, 2001 in MI
- Enrollment address
- 675 W Randall St
Coopersville, MI 49404-1305
All disclosed owners & managing parties 3
| Name | Role | Since | Share |
|---|---|---|---|
| Randall Street Medical, P.C. |
Operational/Managerial Control | Jul 1, 2001 | |
| Roger Holman |
5% Or Greater Direct Ownership Interest | Jul 1, 2001 | |
| Corporate Director | Jul 1, 2001 | ||
| Jody Buist |
W-2 Managing Employee | Sep 1, 2021 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20080721000004 | MI | Part a Provider - Rural Health Clinic | 1951474246 | Practice locations: Coopersville, MI |
| O20120712000410 | MI | Part B Supplier - Clinic/Group Practice | 1951474246 |
Receives reassigned benefits from 4 practitioners Practice locations: Coopersville, MI |
National Provider Directory
Locations
675 W Randall St
Coopersville, MI 49404
Phone (616) 837-9777
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | 5101006733 | MI | Yes |
Addresses
Primary practice location
675 W Randall St
Coopersville, MI 49404-1305
Mailing address
675 W Randall St
Coopersville, MI 49404-1305
Phone (616) 837-9777
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| P57675 | Other | MI | BLUES HMO'S |
| 0027003 | Other | MI | PRIORITY HEALTH HMO |
| 4313667 | Medicaid | MI | |
| 005703574 | Other | MI | BCBSMI |
Other providers in Coopersville, MI
- Lisa Ann Otterbeinbolek
- Heidi Jo Parcher
- Janeen Pastoor
- Dana Ruth Pechumer
- Marie Julliette Poulin
- Rochelle Rawlings
- Karen Elaine Reed-Timmer
- Faith Marie Richards
- Rite Aid of Michigan Inc
- Christina Gale Robertson
All providers in Coopersville, MI · Rural Health Clinic/Center in Michigan
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 22, 2008. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.