1881699668 NPI number — CHARLES RANDALL M.D.

Table of content: CHARLES RANDALL M.D. (NPI 1881699668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881699668 NPI number — CHARLES RANDALL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDALL
Provider First Name:
CHARLES
Provider Middle Name:
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:
1881699668
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
260 MERRIMAC ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWBURYPORT
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01950-2192
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-499-7200
Provider Business Mailing Address Fax Number:
978-499-7216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
260 MERRIMAC ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWBURYPORT
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01950-2192
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-499-7200
Provider Business Practice Location Address Fax Number:
978-499-7216
Provider Enumeration Date:
06/17/2005

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: 207RP1001X , with the licence number:  54597 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 54597 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: A59300 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 0014413 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110045489A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 974558 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 60720 . This is a "HARVARD PILGRIM HEALTHCAR" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J07241 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 48-00612 . This is a "EVERCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 054597 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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