Provider Demographics
NPI:1851468409
Name:PODOLL, RANDAL R (PAC)
Entity type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:R
Last Name:PODOLL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:MI
Mailing Address - Zip Code:49274
Mailing Address - Country:US
Mailing Address - Phone:517-283-1772
Mailing Address - Fax:
Practice Address - Street 1:143 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49274
Practice Address - Country:US
Practice Address - Phone:517-283-1772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIR65483Medicare UPIN