1528085347 NPI number — DR. RANDY DOUGLAS PROFFITT M.D.

Table of content: DR. RANDY DOUGLAS PROFFITT M.D. (NPI 1528085347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528085347 NPI number — DR. RANDY DOUGLAS PROFFITT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROFFITT
Provider First Name:
RANDY
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
DR.
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:
PROFFITT
Provider Other First Name:
RANDY
Provider Other Middle Name:
DOUGLAS
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1528085347
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
740 HILLCREST RD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36695-3924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-607-0300
Provider Business Mailing Address Fax Number:
251-607-0377

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
740 HILLCREST RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36695-3924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-607-0300
Provider Business Practice Location Address Fax Number:
251-607-0377
Provider Enumeration Date:
07/16/2006

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: 2086S0122X , with the licence number:  16402 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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