Provider Demographics
NPI:1598703456
Name:RANDOLPH, ERICH GRAHAM (MD)
Entity Type:Individual
Prefix:
First Name:ERICH
Middle Name:GRAHAM
Last Name:RANDOLPH
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 1:1072 W PEACHTREE ST NW
Mailing Address - Street 2:UNIT 77114
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30357-3016
Mailing Address - Country:US
Mailing Address - Phone:404-300-2476
Mailing Address - Fax:404-250-8010
Practice Address - Street 1:320 PARKWAY DR NE
Practice Address - Street 2:300
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1213
Practice Address - Country:US
Practice Address - Phone:404-522-6569
Practice Address - Fax:404-522-8265
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021790174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000305951RMedicaid
GA92BBGBZOtherMEDICARE PROVIDER ID
GA000305951SMedicaid
GA000305951LMedicaid
GA000305951OMedicaid
GA000305951TMedicaid
GA000305951QMedicaid
GA000305951MMedicaid
GA000305951PMedicaid
GA000305951NMedicaid
GA000305951LMedicaid