Provider Demographics
NPI:1104003987
Name:RANDOLPH MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:RANDOLPH MEDICAL ASSOCIATES
Other - Org Name:IMAGING MOBILITY UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:DOAK
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:334-863-2150
Mailing Address - Street 1:PO BOX 625
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:AL
Mailing Address - Zip Code:36274-0625
Mailing Address - Country:US
Mailing Address - Phone:334-863-2150
Mailing Address - Fax:334-863-8733
Practice Address - Street 1:965 US HWY 431
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:AL
Practice Address - Zip Code:36274
Practice Address - Country:US
Practice Address - Phone:334-863-2150
Practice Address - Fax:334-863-8733
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RANDOLPH MEDICAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD0436246XS1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51091244OtherBCBS
ALE26656OtherUPIN