Provider Demographics
NPI:1326066010
Name:RANDY D. PROFFITT, M.D., LLC
Entity Type:Organization
Organization Name:RANDY D. PROFFITT, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:D
Authorized Official - Last Name:PROFFITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-607-0300
Mailing Address - Street 1:6317 PICCADILLY SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-5103
Mailing Address - Country:US
Mailing Address - Phone:251-344-0322
Mailing Address - Fax:251-344-0395
Practice Address - Street 1:6317 PICCADILLY SQUARE DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-5103
Practice Address - Country:US
Practice Address - Phone:251-344-0322
Practice Address - Fax:251-344-0395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51531824OtherBLUE CROSS
AL051531824Medicaid
AL051531824Medicare PIN
ALE37138Medicare UPIN