Provider Demographics
NPI:1205815735
Name:PALLAS, RANDOLPH S (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:S
Last Name:PALLAS
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 1:301 S 7TH AVE
Mailing Address - Street 2:SUITE 2020
Mailing Address - City:WEST READING
Mailing Address - State:PA
Mailing Address - Zip Code:19611-1410
Mailing Address - Country:US
Mailing Address - Phone:610-375-6565
Mailing Address - Fax:610-375-2065
Practice Address - Street 1:301 S 7TH AVE
Practice Address - Street 2:SUITE 2020
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611-1410
Practice Address - Country:US
Practice Address - Phone:610-375-6565
Practice Address - Fax:610-375-2065
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-038116-E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1091260Medicaid
PA1091260Medicaid
B36714Medicare UPIN