Provider Demographics
NPI:1215017850
Name:BLACK, RANDALL L (MD)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:L
Last Name:BLACK
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 1:1805 N JACKSON
Mailing Address - Street 2:STE 4
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388
Mailing Address - Country:US
Mailing Address - Phone:931-455-9009
Mailing Address - Fax:931-455-6693
Practice Address - Street 1:1805 N JACKSON
Practice Address - Street 2:SUITE 4
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388
Practice Address - Country:US
Practice Address - Phone:931-455-9009
Practice Address - Fax:931-455-6693
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD252632084P0800X
CAG247872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3082256Medicaid
A42390Medicare UPIN
TN3082256Medicaid