1104829134 NPI number — DR. RANDALL FALCONER MD

Table of content: DR. RANDALL FALCONER MD (NPI 1104829134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104829134 NPI number — DR. RANDALL FALCONER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FALCONER
Provider First Name:
RANDALL
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
1104829134
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1728 N EASTMAN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37664-2371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-230-6532
Provider Business Mailing Address Fax Number:
423-230-4859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1728 N EASTMAN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37664-2371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-230-6532
Provider Business Practice Location Address Fax Number:
423-230-4859
Provider Enumeration Date:
05/23/2005

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: 207Y00000X , with the licence number:  MD 18839 , 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: 3036752 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6502512 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".