Provider Demographics
NPI:1003807710
Name:GOLLUB, RANDY LYANNE (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:LYANNE
Last Name:GOLLUB
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-9602
Mailing Address - Fax:617-726-4078
Practice Address - Street 1:185 CAMBRIDGE ST, 2ND FLOOR
Practice Address - Street 2:SIMCHES RESEARCH CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-724-9602
Practice Address - Fax:617-726-4078
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA777202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA077720OtherTUFTS HEALTH PLAN
MA3116271Medicaid
MAJ14229OtherBCBS MA
F07184Medicare UPIN
MAJ14229Medicare ID - Type Unspecified