1639179682 NPI number — DR. RANDALL E PEARSON M.D.

Table of content: DR. RANDALL E PEARSON M.D. (NPI 1639179682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639179682 NPI number — DR. RANDALL E PEARSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEARSON
Provider First Name:
RANDALL
Provider Middle Name:
E
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:
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:
1639179682
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 CROSSROADS DR STE 306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OWINGS MILLS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21117-5437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-738-2872
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 OAK RIDGE TURN PIKE
Provider Second Line Business Practice Location Address:
SUITE A-101
Provider Business Practice Location Address City Name:
OAK RIDGE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37830-6927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-483-1093
Provider Business Practice Location Address Fax Number:
865-482-8629
Provider Enumeration Date:
07/29/2005

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: 208800000X , with the licence number:  MD0000014439 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 020247799 . This is a "EEOICP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1669416442 . This is a "GROUP NPI" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3106049 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3025129 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: CI2260 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3106044 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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