Provider Demographics
NPI:1154396364
Name:RANDALL, KYLE ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:ROBERT
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2911 KNAPP ST NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:616-451-9925
Mailing Address - Fax:616-328-5380
Practice Address - Street 1:2911 KNAPP ST NE
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-451-9925
Practice Address - Fax:616-328-5380
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2014-11-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301061642207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4334872-10Medicaid
MI6187090001Medicare NSC
MI4334872-10Medicaid