Provider Demographics
NPI:1659440006
Name:SHIRLEY M. RANDALL INC
Entity Type:Organization
Organization Name:SHIRLEY M. RANDALL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-483-7706
Mailing Address - Street 1:3105 AMERICAN LEGION RD
Mailing Address - Street 2:STE E
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5654
Mailing Address - Country:US
Mailing Address - Phone:757-483-7706
Mailing Address - Fax:757-483-7726
Practice Address - Street 1:9507 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:NASSAWADOX
Practice Address - State:VA
Practice Address - Zip Code:23413
Practice Address - Country:US
Practice Address - Phone:757-414-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034675207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA=========OtherTAX ID NUMBER