Provider Demographics
NPI:1083684724
Name:TRUDELL, RANDALL GERALD (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:GERALD
Last Name:TRUDELL
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 1:2200 SUTHERLAND AVE.
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919
Mailing Address - Country:US
Mailing Address - Phone:865-521-6174
Mailing Address - Fax:
Practice Address - Street 1:2200 SUTHERLAND AVE.
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919
Practice Address - Country:US
Practice Address - Phone:865-521-6174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN165092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3015861Medicaid
TN3015862Medicare ID - Type Unspecified
TN3015861Medicaid