Provider Demographics
NPI:1538283007
Name:CROSHAW, RANDAL L (MD)
Entity Type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:L
Last Name:CROSHAW
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 1:103 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4703
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:200 BMH CANCER CTR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5922
Practice Address - Country:US
Practice Address - Phone:865-980-5277
Practice Address - Fax:865-980-5278
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000054909208600000X
SC24496208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ023731Medicaid
TN103I026824Medicare PIN
SC244961Medicaid
SC1098109OtherWELLCARE
SC9048669OtherAETNA
SCP01428827OtherRR MEDICARE
SCSC42878568Medicare PIN
MI0Z946010091Medicare PIN