Provider Demographics
NPI:1063572972
Name:RANDALL, KURT ALAN (PT)
Entity type:Individual
Prefix:MR
First Name:KURT
Middle Name:ALAN
Last Name:RANDALL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 STIMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-1513
Mailing Address - Country:US
Mailing Address - Phone:518-505-5878
Mailing Address - Fax:
Practice Address - Street 1:113 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3410
Practice Address - Country:US
Practice Address - Phone:518-626-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023258-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY833278OtherMPN & UNITED HEALTH CAR