1033170972 NPI number — GLENN R RANDALL MD

Table of content: GLENN R RANDALL MD (NPI 1033170972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033170972 NPI number — GLENN R RANDALL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDALL
Provider First Name:
GLENN
Provider Middle Name:
R
Provider Name Prefix Text:
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:
1033170972
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
277 EAST MOUNTAIN ST
Provider Second Line Business Mailing Address:
SUMMIT ELDERCARE
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-852-2026
Provider Business Mailing Address Fax Number:
508-856-7130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
277 EAST MOUNTAIN ST
Provider Second Line Business Practice Location Address:
SUMMIT ELDERCARE
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-852-2026
Provider Business Practice Location Address Fax Number:
508-856-7130
Provider Enumeration Date:
03/30/2006

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: 207R00000X , with the licence number:  80026 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X , with the licence number: 80026 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RH0002X , with the licence number: 80026 , 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: J14922 . This is a "BLUE SHIELD INDEMNITY" identifier . This identifiers is of the category "OTHER".
  • Identifier: J14922 . This is a "MEDICARE B" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110175052 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 27190 . This is a "CHILDRENS MED SEC PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 27190 . This is a "HEALTHY START" identifier . This identifiers is of the category "OTHER".
  • Identifier: 784073 . This is a "MVP HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: J14922 . This is a "BLUE CARE ELECT" identifier . This identifiers is of the category "OTHER".
  • Identifier: J14922 . This is a "BLUE SHIELD HMO BLUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0400961 . This is a "EVERCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "HEALTHCARE VALUE MGMT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1061182 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3131335 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042472266 . This is a "ONE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "PRIVATE HEALTHCARE SYSTEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6633909 . This is a "CIGNA HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7001328 . This is a "AETNA US HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 991122 . This is a "FALLON COMMUNITY HEALTH P" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA2364 . This is a "HARVARD PILGRIM HEALTHCAR" identifier . This identifiers is of the category "OTHER".




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