Provider Demographics
NPI:1740227198
Name:UPDEGROVE, RANDALL LEE (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:LEE
Last Name:UPDEGROVE
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 1:2 DUDLEY ST
Mailing Address - Street 2:SUITE
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-3236
Mailing Address - Country:US
Mailing Address - Phone:401-884-9605
Mailing Address - Fax:
Practice Address - Street 1:1405 S COUNTY TRL
Practice Address - Street 2:SUITE 510
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-5081
Practice Address - Country:US
Practice Address - Phone:401-884-9605
Practice Address - Fax:401-884-9882
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI8772207R00000X
RI087722083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007006717Medicare ID - Type Unspecified
A52620Medicare UPIN