Basic Information
| Provider Information | |||||||||
| NPI: | 1497769665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RANDLE | ||||||||
| FirstName: | GERALD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1151 N STATE ST | ||||||||
| Address2: | SUITE 504 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012924261 | ||||||||
| FaxNumber: | 6012924262 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N STATE ST | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013553353 | ||||||||
| FaxNumber: | 6013553365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 01/14/2014 | ||||||||
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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 | 2084N0400X | 06233 | MS | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | P00466199 | 01 | RR MEDICARE | OTHER | 300002201 | 01 | MS | US DEPT OF LABOR | OTHER | 753068151 | 01 | MS | MPCN | OTHER | 00124228 | 05 | MS | MEDICAID | 753068151 | 01 | MS | MHP | OTHER | 753068151014 | 01 | TRICARE | OTHER |