1013131374 NPI number — GERALD G. RANDOLPH, M.D., INC., P.S.

Table of content: (NPI 1013131374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013131374 NPI number — GERALD G. RANDOLPH, M.D., INC., P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERALD G. RANDOLPH, M.D., INC., P.S.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1013131374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
406 YAUGER WAY SW
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98502-8151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-368-3926
Provider Business Mailing Address Fax Number:
206-575-2874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
406 YAUGER WAY SW
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98502-8151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-575-2875
Provider Business Practice Location Address Fax Number:
206-575-2874
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RANDOLPH
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
GUY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
877-368-3926

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  MD00010827 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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