Provider Demographics
NPI:1124037361
Name:RANDOLPH D. MALONEY, M.D., PC
Entity Type:Organization
Organization Name:RANDOLPH D. MALONEY, M.D., PC
Other - Org Name:NORTH SHORE VASCULAR DIAGNOSTIC LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MALONEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-922-5535
Mailing Address - Street 1:75 HERRICK ST
Mailing Address - Street 2:SUITE 110 - PARKHURST MEDICAL BLDG.
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-5900
Mailing Address - Country:US
Mailing Address - Phone:978-922-5535
Mailing Address - Fax:978-922-5667
Practice Address - Street 1:75 HERRICK ST
Practice Address - Street 2:SUITE 110 - PARKHURST MEDICAL BLDG.
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-5900
Practice Address - Country:US
Practice Address - Phone:978-922-5535
Practice Address - Fax:978-922-5667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARDMS-RVT2471V0105X
MA35297293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes293D00000XLaboratoriesPhysiological Laboratory
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA021569OtherBLUECROSS/BLUESHIELD
MA801461OtherTUFTS
MA9769706Medicaid
MA33434OtherFALLON HEALTH
MA950000914OtherRAILROAD MEDICARE
MA606913OtherHARVARD PILGRAM
MA950000914OtherRAILROAD MEDICARE