Provider Demographics
NPI:1902801962
Name:TAYLOR, RANDOLPH H
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:H
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 THOMAS ROAD
Mailing Address - Street 2:SUITE 117
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291
Mailing Address - Country:US
Mailing Address - Phone:319-329-8194
Mailing Address - Fax:318-329-8196
Practice Address - Street 1:102 THOMAS ROAD
Practice Address - Street 2:SUITE117
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291
Practice Address - Country:US
Practice Address - Phone:319-329-8194
Practice Address - Fax:318-329-8196
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2014-02-11
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-08-09
Provider Licenses
StateLicense IDTaxonomies
LA013943207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAH09001OtherVANTAGE HEALTH PLAN,INC
LA1330744Medicaid
LAB89823Medicare UPIN
LAH09001OtherVANTAGE HEALTH PLAN,INC