Provider Demographics
NPI:1093006009
Name:RANDOLPH, ELIZABETH VANCE (MD)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:VANCE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3786 CENTRAL PIKE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-3497
Mailing Address - Country:US
Mailing Address - Phone:615-883-2200
Mailing Address - Fax:615-883-1104
Practice Address - Street 1:3786 CENTRAL PIKE
Practice Address - Street 2:SUITE 130
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-3497
Practice Address - Country:US
Practice Address - Phone:615-883-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2014-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TNMD0000051215208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program