Provider Demographics
NPI:1255349775
Name:MCCLELLAN, RANDALL DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:DOUGLAS
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 WILLIAMS AVENUE
Mailing Address - Street 2:SUITE 1021
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801
Mailing Address - Country:US
Mailing Address - Phone:256-536-3832
Mailing Address - Fax:256-536-8829
Practice Address - Street 1:303 WILLIAMS AVENUE
Practice Address - Street 2:SUITE 1021
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801
Practice Address - Country:US
Practice Address - Phone:256-536-3832
Practice Address - Fax:256-536-8829
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000245492080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL00937065Medicaid
AL51516878OtherBC
H72414Medicare UPIN