Basic Information
| Provider Information | |||||||||
| NPI: | 1083826408 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RANDALL P. MAYDEW, M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 WELBORN ST APT 420 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752195215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4699640807 | ||||||||
| FaxNumber: | 2143637036 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 FOREST LN | ||||||||
| Address2: | SUITE B238 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725665813 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2007 | ||||||||
| LastUpdateDate: | 05/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | MAYDEW | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE PROPRIETOR | ||||||||
| AuthorizedOfficialTelephone: | 4699640807 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | J0589 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | P8B057101 | 05 | TX | MEDICAID | 263088 | 05 | AZ | MEDICAID | 1255350757 | 01 | PERSONAL NPI NUMBER | OTHER | 33605 | 05 | NM | MEDICAID | 91842187 | 05 | CO | MEDICAID | 0529554-02 | 05 | TX | MEDICAID |