Provider Demographics
NPI:1346200573
Name:MUDGE, RANDY (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:
Last Name:MUDGE
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 1:300 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-3307
Mailing Address - Country:US
Mailing Address - Phone:269-245-8056
Mailing Address - Fax:269-966-8593
Practice Address - Street 1:300 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3307
Practice Address - Country:US
Practice Address - Phone:269-966-8334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010576992085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4434125Medicaid
MION56590Medicare ID - Type Unspecified
MI4434125Medicaid