Basic Information
| Provider Information | |||||||||
| NPI: | 1760882690 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RANDOLPH | ||||||||
| FirstName: | DERRICK | ||||||||
| MiddleName: | AARON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2030 CLEVELAND AVE S.W | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563533501 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1207 7TH ST S.E. | ||||||||
| Address2: | DECATUR/MORGAN HOSPITAL - PARKWAY CAMPUS | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 35601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563412000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2014 | ||||||||
| LastUpdateDate: | 01/27/2015 | ||||||||
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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 | 163W00000X | 1-090988 | AL | N | Nursing Service Providers | Registered Nurse | 390200000X | 1-090988 | AL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363LF0000X | 1-090988 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.