Provider Demographics
NPI:1881699668
Name:RANDALL, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:RANDALL
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 1:260 MERRIMAC ST
Mailing Address - Street 2:
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-2192
Mailing Address - Country:US
Mailing Address - Phone:978-499-7200
Mailing Address - Fax:978-499-7216
Practice Address - Street 1:260 MERRIMAC ST
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-2192
Practice Address - Country:US
Practice Address - Phone:978-499-7200
Practice Address - Fax:978-499-7216
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54597207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHA59300OtherANTHEM BLUE CROSS
0014413OtherCIGNA
MA110045489AMedicaid
MA974558OtherNETWORK HEALTH
MA60720OtherHARVARD PILGRIM HEALTHCAR
MAJ07241OtherBLUE CROSS BLUE SHIELD
MA48-00612OtherEVERCARE
MA054597OtherTUFTS HEALTH PLAN
MA48-00612OtherEVERCARE
MA110045489AMedicaid