Provider Demographics
NPI:1164448239
Name:ROBERTSON, RANDOLPH HARLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:HARLEN
Last Name:ROBERTSON
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 1:142 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-1760
Mailing Address - Country:US
Mailing Address - Phone:931-528-2541
Mailing Address - Fax:931-526-8814
Practice Address - Street 1:6119 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-3072
Practice Address - Country:US
Practice Address - Phone:260-432-1568
Practice Address - Fax:260-432-4969
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN181292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050269Medicaid
TN300114288OtherRAILROAD MEDICARE
TN3037577Medicaid
TN3156107OtherBCBS
IN201023920Medicaid
TNB00078Medicare UPIN
INM400048362Medicare PIN
MIMI1209040Medicare PIN
IN201023920Medicaid
INP00950297Medicare PIN