Randolph, Gannon B
Randolph, Gannon B is an individual health care provider with primary practice located at 1800 Se Moberly Ln , Bentonville AR 72712-7017. He recently has 2 registered licenses in different health care specialties including Allopathic & Osteopathic Physicians / Orthopaedic Surgery, Allopathic & Osteopathic Physicians / Orthopaedic Surgery of the Spine. Allopathic & Osteopathic Physicians / Orthopaedic Surgery of the Spine is his primary health care specialty. Randolph, Gannon B can be contacted via phone (479) 521-2752.Contact Information
Primary practice address
1800 Se Moberly Ln
Bentonville AR 72712-7017
Phone: (479) 521-2752
Fax: (479) 521-4603
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Allopathic & Osteopathic Physicians / Orthopaedic Surgery | 207X00000X | E5957 | Arkansas |
| Allopathic & Osteopathic Physicians / Orthopaedic Surgery of the Spine | 207XS0117X | E5957 | Arkansas |
Profile Details
| NPI number | 1528173697 |
|---|---|
| LBN Legal business name | Randolph, Gannon B |
| Credentials | Doctor of Medicine (MD) |
| Entity | Individual |
| Sole proprietor 1 | No |
| Enumeration date | Aug 20th, 2006 |
| Last updated | Jul 12th, 2021 - about 4 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1528173697 | NPPES |
| Arkansas | MEDICAID | 1176259001 |
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