Basic Information
| Provider Information | |||||||||
| NPI: | 1710986450 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RANDOLPH | ||||||||
| FirstName: | FELICIA | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 HAMLIN BLVD | ||||||||
| Address2: | |||||||||
| City: | INKSTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481412206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135615100 | ||||||||
| FaxNumber: | 3135615100 | ||||||||
| Practice Location | |||||||||
| Address1: | 2888 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138755377 | ||||||||
| FaxNumber: | 3138755727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 09/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301074153 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4583949 | 05 | MI | MEDICAID |