Provider Demographics
NPI:1720527021
Name:RANDALL P WEYRICH MD LLC
Entity Type:Organization
Organization Name:RANDALL P WEYRICH MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:P
Authorized Official - Last Name:WEYRICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-639-3427
Mailing Address - Street 1:6602 SEABIRD WAY
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-3003
Mailing Address - Country:US
Mailing Address - Phone:304-639-3427
Mailing Address - Fax:813-498-0355
Practice Address - Street 1:6602 SEABIRD WAY
Practice Address - Street 2:
Practice Address - City:APOLLO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33572-3003
Practice Address - Country:US
Practice Address - Phone:304-639-3427
Practice Address - Fax:813-498-0355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111722207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019027800Medicaid