Provider Demographics
NPI:1497756258
Name:RANDOLPH, BONNIE F (MD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:F
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 CHESHIRE CIR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37069-7191
Mailing Address - Country:US
Mailing Address - Phone:615-646-9114
Mailing Address - Fax:615-646-9114
Practice Address - Street 1:310 21ST AVE N
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1846
Practice Address - Country:US
Practice Address - Phone:629-253-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD38270207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3892235Medicaid
TN103I930699Medicare PIN
I05124Medicare UPIN
TN3892235Medicare PIN
TN38922311Medicare PIN
TNP00405532Medicare PIN