| Organization Name: | RANDALL STREET MEDICAL PC |
| NPI Number: | 1598734584 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | ROGER HOLMAN (OWNER/PHYSICIAN) |
| Mailing Address: | 675 W Randall St Coopersville |
| State: | MI US |
| Postal Code: | 494041305 |
| Phone Number: | 6168379777 |
| Fax Number: | 6168377813 |
| NPI Enumeration Date: | 03/14/2006 |
| NPI Last Update Date: | 07/22/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QR1300X |
| License Number: | 5101006733 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Rural Health |
| Taxonomy Definition: | |