Provider Demographics
NPI:1548329485
Name:RANDALL MAXEY MD CORP
Entity type:Organization
Organization Name:RANDALL MAXEY MD CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:W
Authorized Official - Last Name:MAXEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:310-680-1810
Mailing Address - Street 1:PO BOX 83246
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90083-0246
Mailing Address - Country:US
Mailing Address - Phone:310-680-1810
Mailing Address - Fax:310-680-1811
Practice Address - Street 1:323 N PRAIRIE AVE
Practice Address - Street 2:SUITE 417
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4502
Practice Address - Country:US
Practice Address - Phone:310-680-1810
Practice Address - Fax:310-680-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16418Medicare Oscar/Certification
CAW16418Medicare PIN