Provider Demographics
NPI:1720197122
Name:SUGERMAN, RANDAL (MD)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:
Last Name:SUGERMAN
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 1:5925 ZEBULON RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1917
Mailing Address - Country:US
Mailing Address - Phone:478-757-7865
Mailing Address - Fax:
Practice Address - Street 1:3400 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2513
Practice Address - Country:US
Practice Address - Phone:478-474-5600
Practice Address - Fax:478-471-6769
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036465208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000557928EMedicaid
A66200Medicare UPIN
GA000557928EMedicaid