Provider Demographics
NPI:1457820920
Name:RANDALL L BRADDOM MD LLC
Entity Type:Organization
Organization Name:RANDALL L BRADDOM MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRADDOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-601-7036
Mailing Address - Street 1:1093 GOLDEN GROVE DR
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-4023
Mailing Address - Country:US
Mailing Address - Phone:908-601-7036
Mailing Address - Fax:
Practice Address - Street 1:1451 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32159-0041
Practice Address - Country:US
Practice Address - Phone:352-751-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty