1265413280 NPI number — MRS. BEVERLY MICHELLE RANDOLPH PT

Table of content: MRS. BEVERLY MICHELLE RANDOLPH PT (NPI 1265413280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265413280 NPI number — MRS. BEVERLY MICHELLE RANDOLPH PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDOLPH
Provider First Name:
BEVERLY
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRADLEY
Provider Other First Name:
BEVERLY
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265413280
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
810 S BROOM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19805-4245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-652-1181
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
810 S BROOM ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19805-4245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-652-1181
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/08/2005

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: 225100000X , with the licence number:  J10001461 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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