Provider Demographics
NPI:1700337979
Name:RANDOLPH, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 N HOLTON ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1008
Mailing Address - Country:US
Mailing Address - Phone:414-899-6838
Mailing Address - Fax:
Practice Address - Street 1:4200 N HOLTON ST STE 110
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1065
Practice Address - Country:US
Practice Address - Phone:414-899-6838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WP1700X163WP1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP1700XNursing Service ProvidersRegistered NursePerinatal