1497736243 NPI number — MR. RANDY DANIEL MCDONALD CRNA

Table of content: MR. RANDY DANIEL MCDONALD CRNA (NPI 1497736243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497736243 NPI number — MR. RANDY DANIEL MCDONALD CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDONALD
Provider First Name:
RANDY
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497736243
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2480 LLEWELLYN AVE
Provider Second Line Business Mailing Address:
KIMBROUGH AMBULATORY CARE CENTER
Provider Business Mailing Address City Name:
FT MEADE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20755-5800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-677-8011
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2480 LLEWELLYN AVE
Provider Second Line Business Practice Location Address:
KIMBROUGH AMBULATORY CARE CENTER
Provider Business Practice Location Address City Name:
FT MEADE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20755-5800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-677-8011
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  380-708-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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