Provider Demographics
NPI:1306877634
Name:HINES, RANDALL STUART (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:STUART
Last Name:HINES
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 1:2500 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-7641
Mailing Address - Country:US
Mailing Address - Phone:601-936-3650
Mailing Address - Fax:866-491-0274
Practice Address - Street 1:2500 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-7641
Practice Address - Country:US
Practice Address - Phone:601-936-3650
Practice Address - Fax:866-491-0274
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12123207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014712Medicaid
MS160039613OtherRR MEDICARE NUMBER
MS00116795Medicaid
MS08103071OtherUP MEDICAID GROUP PROV#
MS512I160006OtherMEDICARE PTAN
MS512G700003OtherUP MEDICARE GROUP PROV#
MSC00319Medicare ID - Type UnspecifiedMCRE GROUP PROV NUMBER
MS00116795Medicaid
MS512I160006OtherMEDICARE PTAN