1295733772 NPI number — RANDOLPH R EVANS MD

Table of content: RANDOLPH R EVANS MD (NPI 1295733772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295733772 NPI number — RANDOLPH R EVANS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
RANDOLPH
Provider Middle Name:
R
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:
1295733772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1670 W MAIN ST
Provider Second Line Business Mailing Address:
STE100
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37087-1344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-453-5155
Provider Business Mailing Address Fax Number:
615-444-5915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1670 W MAIN ST
Provider Second Line Business Practice Location Address:
STE100
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37087-1344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-453-5155
Provider Business Practice Location Address Fax Number:
615-444-5915
Provider Enumeration Date:
07/08/2005

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: 207W00000X , with the licence number:  18805 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4065401 . This is a "AETNA PPO" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1238610001 . This is a "DMERC" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 180006421 . This is a "PALMETTO GBA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 000089791 . This is a "BCBS ADVANTAGE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3032849 . This is a "HEALTHSPRING" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 000089791 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3389788 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 621298175 . This is a "DEFAULT" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 000089791 . This is a "TENNCARE SELECT" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 186641053 . This is a "VISION SERVICE PLAN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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