Basic Information
| Provider Information | |||||||||
| NPI: | 1164448239 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | RANDOLPH | ||||||||
| MiddleName: | HARLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 142 W 5TH ST | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385011760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315282541 | ||||||||
| FaxNumber: | 9315268814 | ||||||||
| Practice Location | |||||||||
| Address1: | 6119 W JEFFERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468043072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604321568 | ||||||||
| FaxNumber: | 2604324969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 02/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 18129 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0050269 | 05 | OH | MEDICAID | 300114288 | 01 | TN | RAILROAD MEDICARE | OTHER | 3037577 | 05 | TN | MEDICAID | 3156107 | 01 | TN | BCBS | OTHER | 201023920 | 05 | IN | MEDICAID |