Provider Demographics
NPI:1699799007
Name:SERCOMBE, RANDALL (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:SERCOMBE
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 1:6545 FRANCE AVE S
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2131
Mailing Address - Country:US
Mailing Address - Phone:952-920-9191
Mailing Address - Fax:952-920-0232
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:SUITE 400
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2131
Practice Address - Country:US
Practice Address - Phone:952-920-9191
Practice Address - Fax:952-920-0232
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36050208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2M165SEOtherBLUE CROSS BLUE SHIELD
1227878OtherMEDICA
CP9021000008OtherPREFERRED ONE
F52454Medicare UPIN