Provider Demographics
NPI:1073586970
Name:RHEA, RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:RHEA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 CENTER HILL DR SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-3629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 S POLLARD ST
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179-2502
Practice Address - Country:US
Practice Address - Phone:540-983-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-034637207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005623944Medicaid
VA005638127Medicaid
VA5637864Medicaid
080005655Medicare PIN
VA005623944Medicaid
VA5637864Medicaid
VA005638127Medicaid