Provider Demographics
NPI:1710986450
Name:RANDOLPH, FELICIA R (MD)
Entity Type:Individual
Prefix:DR
First Name:FELICIA
Middle Name:R
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2700 HAMLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-2206
Mailing Address - Country:US
Mailing Address - Phone:313-561-5100
Mailing Address - Fax:313-561-5100
Practice Address - Street 1:2888 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2612
Practice Address - Country:US
Practice Address - Phone:313-875-5377
Practice Address - Fax:313-875-5727
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301074153207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4583949Medicaid
MII08719Medicare UPIN
MION92410Medicare ID - Type Unspecified