Provider Demographics
NPI:1760511067
Name:SILLYMAN, RANDY LEE (PT)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:LEE
Last Name:SILLYMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 KEEFAUVER RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4410
Mailing Address - Country:US
Mailing Address - Phone:423-282-5894
Mailing Address - Fax:423-282-5895
Practice Address - Street 1:366 KEEFAUVER RD
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:TN
Practice Address - Zip Code:37615-4410
Practice Address - Country:US
Practice Address - Phone:423-282-5894
Practice Address - Fax:423-282-5895
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000006609225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPSS0000000228Medicaid