Provider Demographics
NPI:1194052555
Name:WILLIAM E. RANDALL, JR., M.D. P.A.
Entity type:Organization
Organization Name:WILLIAM E. RANDALL, JR., M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EDDY
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:410-823-1313
Mailing Address - Street 1:1205 YORK RD
Mailing Address - Street 2:SUITE 33
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-6210
Mailing Address - Country:US
Mailing Address - Phone:410-823-1313
Mailing Address - Fax:410-823-1316
Practice Address - Street 1:1205 YORK RD
Practice Address - Street 2:SUITE 33
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6210
Practice Address - Country:US
Practice Address - Phone:410-823-1313
Practice Address - Fax:410-823-1316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2010-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0015808207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
06372OtherAMERIGROUP
34794001OtherBLUE SHIELD
4070033OtherAETNA
E181OtherFEDERAL BS
MD003951900Medicaid
443218OtherAMERIHEALTH
MD1720047988Medicare UPIN
MD003951900Medicaid