Provider Demographics
NPI:1205901949
Name:DRAIN, RANDALL TERENCE SR (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:TERENCE
Last Name:DRAIN
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3847 NORTH SYDENHAM STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140
Mailing Address - Country:US
Mailing Address - Phone:215-227-3300
Mailing Address - Fax:215-227-3118
Practice Address - Street 1:4035 POWELTON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2262
Practice Address - Country:US
Practice Address - Phone:215-471-7000
Practice Address - Fax:215-474-0457
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD039729L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1054660Medicaid
PA1054660Medicaid