1194052555 NPI number — WILLIAM E. RANDALL, JR., M.D. P.A.

Table of content: (NPI 1194052555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194052555 NPI number — WILLIAM E. RANDALL, JR., M.D. P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM E. RANDALL, JR., M.D. P.A.
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:
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:
1194052555
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1205 YORK RD
Provider Second Line Business Mailing Address:
SUITE 33
Provider Business Mailing Address City Name:
LUTHERVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21093-6210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-823-1313
Provider Business Mailing Address Fax Number:
410-823-1316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1205 YORK RD
Provider Second Line Business Practice Location Address:
SUITE 33
Provider Business Practice Location Address City Name:
LUTHERVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21093-6210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-823-1313
Provider Business Practice Location Address Fax Number:
410-823-1316
Provider Enumeration Date:
11/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
RANDALL
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
EDDY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
410-823-1313

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  D0015808 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 06372 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 34794001 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4070033 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: E181 . This is a "FEDERAL BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 003951900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 443218 . This is a "AMERIHEALTH" identifier . This identifiers is of the category "OTHER".




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