Provider Demographics
NPI:1255395273
Name:SWAIN, RANDALL ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:ALAN
Last Name:SWAIN
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 1:415 MORRIS ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1842
Mailing Address - Country:US
Mailing Address - Phone:304-388-7783
Mailing Address - Fax:304-388-7788
Practice Address - Street 1:4602 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1848
Practice Address - Country:US
Practice Address - Phone:304-925-4777
Practice Address - Fax:304-925-4780
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16120207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0042952-000Medicaid
P00058528OtherRAILROAD MEDICARE
WV0042952000Medicaid
G56633Medicare UPIN
WVWV0657DMedicare PIN
SW0661658Medicare PIN
WVWV0657AMedicare PIN
RA4222451Medicare PIN
P00058528Medicare PIN
WV0042952-000Medicaid
WVWV0657CMedicare PIN
WVWV0657BMedicare PIN