Provider Demographics
NPI:1144253642
Name:CHRISTENSON, RANDALL M (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:M
Last Name:CHRISTENSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 60TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7065
Mailing Address - Country:US
Mailing Address - Phone:616-719-4488
Mailing Address - Fax:616-719-4480
Practice Address - Street 1:1403 60TH ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-7065
Practice Address - Country:US
Practice Address - Phone:616-719-4488
Practice Address - Fax:616-719-4480
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010459112084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI103371307Medicaid
MI260D110830OtherBLUE CROSS BLUE SHIELD
MI380001205OtherRAILROAD MEDICARE
MIA75984Medicare UPIN
MI0M42950002Medicare ID - Type Unspecified
MI103371307Medicaid