Healthcare Provider Details

I. General information

NPI: 1578806436
Provider Name (Legal Business Name): MICHELLE RANDOLPH MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 DEBARR ROAD SUITE 402
ANCHORAGE AK
99508
US

IV. Provider business mailing address

2741 DEBARR ROAD SUITE 402
ANCHORAGE AK
99508
US

V. Phone/Fax

Practice location:
  • Phone: 907-531-5213
  • Fax: 907-531-5013
Mailing address:
  • Phone: 907-531-5213
  • Fax: 907-531-5013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number7641
License Number StateAK

VIII. Authorized Official

Name: DR. MICHELLE LISA RANDOLPH
Title or Position: PRESIDENT
Credential: MD
Phone: 808-295-6058