1124002175 NPI number — M. BARRY RANDALL M.D.

Table of content: M. BARRY RANDALL M.D. (NPI 1124002175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124002175 NPI number — M. BARRY RANDALL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDALL
Provider First Name:
M.
Provider Middle Name:
BARRY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1124002175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1407 UNION AVE
Provider Second Line Business Mailing Address:
SUITE 700
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38104-3627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-866-8375
Provider Business Mailing Address Fax Number:
901-302-2360

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 MADISON AVE
Provider Second Line Business Practice Location Address:
SUITE 890
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38103-3410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-866-8834
Provider Business Practice Location Address Fax Number:
901-302-2834
Provider Enumeration Date:
12/02/2005

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: 207ZP0102X , with the licence number:  029321 , 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: 0121423 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 133395001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1532078 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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