Provider Demographics
NPI:1346236155
Name:O'BRIEN, RANDALL FREDERICK (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:FREDERICK
Last Name:O'BRIEN
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:PO BOX 2267
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31502-2267
Mailing Address - Country:US
Mailing Address - Phone:912-283-9309
Mailing Address - Fax:912-287-1231
Practice Address - Street 1:2003 ALICE ST
Practice Address - Street 2:SUITE A
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6209
Practice Address - Country:US
Practice Address - Phone:912-287-1130
Practice Address - Fax:912-287-9114
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA43249174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA200040070OtherPALMETTO GBA
GA00764772CMedicaid
20BBFDRMedicare ID - Type Unspecified
GA00764772CMedicaid
GAF45932Medicare UPIN