Provider Demographics
NPI:1396893830
Name:RANDOLPH V MERRICK, MD, PC
Entity type:Organization
Organization Name:RANDOLPH V MERRICK, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:V
Authorized Official - Last Name:MERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-661-0263
Mailing Address - Street 1:303 MADISON RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORANGE
Mailing Address - State:VA
Mailing Address - Zip Code:22960-1015
Mailing Address - Country:US
Mailing Address - Phone:540-661-0263
Mailing Address - Fax:540-672-5264
Practice Address - Street 1:303 MADISON RD
Practice Address - Street 2:SUITE B
Practice Address - City:ORANGE
Practice Address - State:VA
Practice Address - Zip Code:22960-1015
Practice Address - Country:US
Practice Address - Phone:540-661-0263
Practice Address - Fax:540-672-5264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09718Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER