Provider Demographics
NPI:1447483185
Name:RANDY S.BEALLIS D.O. P.A.
Entity type:Organization
Organization Name:RANDY S.BEALLIS D.O. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BEALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:479-459-5382
Mailing Address - Street 1:PO BOX 11106
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1106
Mailing Address - Country:US
Mailing Address - Phone:479-459-5382
Mailing Address - Fax:
Practice Address - Street 1:7301 ROGERS AVE FL 4
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4100
Practice Address - Country:US
Practice Address - Phone:479-646-5700
Practice Address - Fax:479-646-5956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-28
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC-2708207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK11699Medicare PIN
ILG80586Medicare UPIN