Healthcare Provider Details

I. General information

NPI: 1548329485
Provider Name (Legal Business Name): RANDALL MAXEY MD CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 12/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 N PRAIRIE AVE SUITE 417
INGLEWOOD CA
90301-4502
US

IV. Provider business mailing address

PO BOX 83246
LOS ANGELES CA
90083-0246
US

V. Phone/Fax

Practice location:
  • Phone: 310-680-1810
  • Fax: 310-680-1811
Mailing address:
  • Phone: 310-680-1810
  • Fax: 310-680-1811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. RANDALL W MAXEY
Title or Position: PRESIDENT
Credential: MD, PH.D.
Phone: 310-680-1810