Provider Demographics
NPI:1750468005
Name:RANDY HEAD, MD, APMC
Entity Type:Organization
Organization Name:RANDY HEAD, MD, APMC
Other - Org Name:MONROE REGIONAL MEDICAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:W
Authorized Official - Last Name:HEAD
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:318-387-3888
Mailing Address - Street 1:1470 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-3913
Mailing Address - Country:US
Mailing Address - Phone:318-387-3888
Mailing Address - Fax:318-324-8967
Practice Address - Street 1:1470 GARRETT RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-3913
Practice Address - Country:US
Practice Address - Phone:318-387-3888
Practice Address - Fax:318-324-8967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1444987Medicaid
LA022410OtherSTATE LICENSE
LA=========OtherTAX ID
LAG121269Medicare UPIN
LA5CT83Medicare PIN