Provider Demographics
NPI:1013131374
Name:GERALD G. RANDOLPH, M.D., INC., P.S.
Entity type:Organization
Organization Name:GERALD G. RANDOLPH, M.D., INC., P.S.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:GUY
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-368-3926
Mailing Address - Street 1:406 YAUGER WAY SW
Mailing Address - Street 2:SUITE B
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8151
Mailing Address - Country:US
Mailing Address - Phone:877-368-3926
Mailing Address - Fax:206-575-2874
Practice Address - Street 1:406 YAUGER WAY SW
Practice Address - Street 2:SUITE B
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8151
Practice Address - Country:US
Practice Address - Phone:206-575-2875
Practice Address - Fax:206-575-2874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00010827261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty