Basic Information
| Provider Information | |||||||||
| NPI: | 1538173489 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RANDOLPH EYE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27 MEMORIAL PKWY | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023684505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819867400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27 MEMORIAL PKWY | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023684505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819867400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 09/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | CLINE | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7819867400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 708853A | 01 | MA | TUFTS | OTHER | 1152531 | 01 | UHC GROUP | OTHER | W20030 | 01 | MA | BCBS GROUP | OTHER | 9726659 | 05 | MA | MEDICAID |