Provider Demographics
NPI:1841203023
Name:RANDOLPH, MARY KAY (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:KAY
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36584 W 220TH ST
Mailing Address - Street 2:
Mailing Address - City:POLO
Mailing Address - State:MO
Mailing Address - Zip Code:64671-8669
Mailing Address - Country:US
Mailing Address - Phone:816-809-7730
Mailing Address - Fax:
Practice Address - Street 1:36584 W 220TH ST
Practice Address - Street 2:
Practice Address - City:POLO
Practice Address - State:MO
Practice Address - Zip Code:64671-8669
Practice Address - Country:US
Practice Address - Phone:816-809-7730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-121726207Q00000X
KS04-25049207Q00000X
MO101542207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS068002402OtherMEDICARE PTAN
KS100175570CMedicaid
OK100185760AMedicare ID - Type Unspecified
F87600Medicare UPIN
MO067050049Medicare ID - Type Unspecified