1194726380 NPI number — GEOFFREY M RANDOLPH MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194726380 NPI number — GEOFFREY M RANDOLPH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDOLPH
Provider First Name:
GEOFFREY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194726380
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7230 ENGLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46804-2209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-490-7111
Provider Business Mailing Address Fax Number:
260-490-9301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11141 PARKVIEW PLAZA DR STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46845-1715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-490-7111
Provider Business Practice Location Address Fax Number:
260-490-9301
Provider Enumeration Date:
08/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  01035742A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 240007528 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 104366820 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0467338 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100353210 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com