Provider Demographics
NPI:1477724987
Name:CHRISTOPHER C RANDOLPH
Entity Type:Organization
Organization Name:CHRISTOPHER C RANDOLPH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:CRONIN
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-755-7080
Mailing Address - Street 1:1389 W MAIN ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3104
Mailing Address - Country:US
Mailing Address - Phone:203-755-7080
Mailing Address - Fax:203-346-6244
Practice Address - Street 1:1389 W MAIN ST
Practice Address - Street 2:SUITE 205
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3104
Practice Address - Country:US
Practice Address - Phone:203-755-7080
Practice Address - Fax:203-346-6244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT027063207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02498Medicare PIN