Provider Demographics
NPI:1578507794
Name:CROSS, RANDALL J (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:J
Last Name:CROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 505673
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5673
Mailing Address - Country:US
Mailing Address - Phone:417-269-3319
Mailing Address - Fax:417-875-3490
Practice Address - Street 1:1000 E PRIMROSE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5154
Practice Address - Country:US
Practice Address - Phone:417-269-3319
Practice Address - Fax:417-875-3490
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1G20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4242OtherBCBS
193649OtherHEALTHLINK
MO202314084Medicaid
001014190Medicare PIN
4242OtherBCBS