Basic Information
| Provider Information | |||||||||
| NPI: | 1104003987 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RANDOLPH MEDICAL ASSOCIATES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | IMAGING MOBILITY UNIT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 625 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 362740625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348632150 | ||||||||
| FaxNumber: | 3348638733 | ||||||||
| Practice Location | |||||||||
| Address1: | 965 US HWY 431 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348632150 | ||||||||
| FaxNumber: | 3348638733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2008 | ||||||||
| LastUpdateDate: | 01/24/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | DOAK | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3348632150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RANDOLPH MEDICAL ASSOCIATES | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246XS1301X | D0436 | AL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Spec/Tech, Cardiovascular | Sonography |
ID Information
| ID | Type | State | Issuer | Description | 51091244 | 01 | AL | BCBS | OTHER | E26656 | 01 | AL | UPIN | OTHER |