Basic Information
| Provider Information | |||||||||
| NPI: | 1255336434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOOVER | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 E SPRINGBROOK DR | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376011761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237945520 | ||||||||
| FaxNumber: | 4232826940 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 MED TECH PKWY | ||||||||
| Address2: | STE 240 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237945520 | ||||||||
| FaxNumber: | 4232826940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 37366 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1255336434 | 05 | VA | MEDICAID | 3885549 | 05 | TN | MEDICAID |