Provider Demographics
NPI:1952484941
Name:RANDALL, TERRI (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRI
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4414
Mailing Address - Country:US
Mailing Address - Phone:215-503-2838
Mailing Address - Fax:215-923-8219
Practice Address - Street 1:833 CHESTNUT ST
Practice Address - Street 2:SUITE 210
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4414
Practice Address - Country:US
Practice Address - Phone:215-503-2838
Practice Address - Fax:215-923-8219
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4265912084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102176015Medicaid
PA128300PAGMedicare PIN