Provider Demographics
NPI:1609347947
Name:RANDOLPH, JEFFREY MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17600 EIDER DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-7408
Mailing Address - Country:US
Mailing Address - Phone:586-321-7217
Mailing Address - Fax:586-286-4988
Practice Address - Street 1:1411 3RD ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5480
Practice Address - Country:US
Practice Address - Phone:586-651-6059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010945225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist