Provider Demographics
NPI:1467453357
Name:GORMAN, RANDOLPH B (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:B
Last Name:GORMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:110 WEST RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2316
Mailing Address - Country:US
Mailing Address - Phone:410-296-4616
Mailing Address - Fax:410-337-5068
Practice Address - Street 1:6701 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-6808
Practice Address - Country:US
Practice Address - Phone:410-296-4616
Practice Address - Fax:410-337-5068
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0043901207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD203091800Medicaid
MDD0043901OtherSTATE LICENSE NUMBER
MDH506750MMedicare PIN
MDF60771Medicare UPIN