Provider Demographics
NPI:1225211360
Name:MICHAEL A. RANDOLPH, MD PC
Entity type:Organization
Organization Name:MICHAEL A. RANDOLPH, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-261-8977
Mailing Address - Street 1:200 E 33RD ST
Mailing Address - Street 2:SUITE 136
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-3322
Mailing Address - Country:US
Mailing Address - Phone:410-261-8997
Mailing Address - Fax:410-337-0385
Practice Address - Street 1:200 E 33RD ST
Practice Address - Street 2:SUITE 136
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-3322
Practice Address - Country:US
Practice Address - Phone:410-261-8997
Practice Address - Fax:410-337-0385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0034680207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF54170Medicare UPIN
MD289MMedicare PIN