Provider Demographics
NPI:1346248671
Name:RAULS, STEPHEN RANDOLPH (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RANDOLPH
Last Name:RAULS
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 1:877 JEFFERSON AVENUE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2807
Mailing Address - Country:US
Mailing Address - Phone:901-545-6286
Mailing Address - Fax:901-545-8122
Practice Address - Street 1:880 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3409
Practice Address - Country:US
Practice Address - Phone:901-515-3500
Practice Address - Fax:901-545-3509
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC 5444207V00000X
TN67750207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B90510Medicare UPIN
54268Medicare ID - Type Unspecified