Provider Demographics
NPI:1558580399
Name:SEVERANCE, RANDALL JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:JAMES
Last Name:SEVERANCE
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 1:2116 E KNOX RD
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3530
Mailing Address - Country:US
Mailing Address - Phone:480-456-8812
Mailing Address - Fax:
Practice Address - Street 1:924 W CHANDLER BLVD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-2528
Practice Address - Country:US
Practice Address - Phone:480-775-1115
Practice Address - Fax:480-775-1118
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19969207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE82218Medicare UPIN