Randall Ellis Jack, M.D.

Primary specialty

Gynecology PhysicianTaxonomy code 207VG0400X

License

13040 Issued in NV

Practice address

635 Innovation Dr Ste 300
Reno, NV 89511-2215

Phone

(775) 329-6241

Fax

(775) 329-4921

NPI assigned

Jun 22, 2006

Last updated

Apr 12, 2024By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Apr 1, 2015 through Apr 1, 2027

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Springfield Health Services, LLC

  dba NorthCrest Medical Center

  • General Acute Care Hospital
  • Springfield, TN
  • NPI 1093397184
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150934400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1712880000000",
    "number": "1922044437",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "635 INNOVATION DR STE 300",
            "city": "RENO",
            "state": "NV",
            "postal_code": "895112215",
            "telephone_number": "775-329-6241",
            "fax_number": "775-329-4921"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "635 INNOVATION DR STE 300",
            "city": "RENO",
            "state": "NV",
            "postal_code": "895112215",
            "telephone_number": "775-329-6241",
            "fax_number": "775-329-4921"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACK",
        "first_name": "RANDALL",
        "middle_name": "ELLIS",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-22",
        "last_updated": "2024-04-12",
        "certification_date": "2024-04-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207VG0400X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology, Gynecology",
            "state": "NV",
            "license": "13040",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jabel's Place
• Stephen Lloyd Jachimowicz
• Edward Joseph Jack
• Hunter Jack
• Mykayla E. Jack
• Jackalope Holistic Healing LLC
• Jackie Burgess Midwifery (Northern Nevada Midwives Association)
• Amy Ruth Jackson, CADC
• Angela Jackson, M.S. SLP-CCC
• Barbara Anne Jackson

• Gynecology Physician in Reno, NV
• Providers in Reno, NV by specialty
• Gynecology Physician in Nevada

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 12, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.