Provider Demographics
NPI:1538235171
Name:RANDOLPH, BRUCE WENDELL (MEDICAL DOCTOR)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:WENDELL
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 KNIGHT ARNOLD RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118
Mailing Address - Country:US
Mailing Address - Phone:901-547-1911
Mailing Address - Fax:901-547-1905
Practice Address - Street 1:3960 KNIGHT ARNOLD RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118
Practice Address - Country:US
Practice Address - Phone:901-547-1911
Practice Address - Fax:901-547-1905
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN276862083X0100X
MS108352083X0100X
OK168972083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
3818713Medicare ID - Type Unspecified
B64615Medicare UPIN