Provider Demographics
NPI:1063589216
Name:SMITH, RANDOLPH EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:EDWARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W MAGNETIC ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2711
Mailing Address - Country:US
Mailing Address - Phone:906-228-9440
Mailing Address - Fax:
Practice Address - Street 1:420 W MAGNETIC ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2711
Practice Address - Country:US
Practice Address - Phone:906-228-9440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046452207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2746496OtherMOLINA HEALTHCARE
WI34031400Medicaid
MI2746796Medicaid
MI1022271OtherPREFERRED ONE
MI2746796OtherHEALTHPLAN OF MI
WI34031400Medicaid