Healthcare Provider Details

I. General information

NPI: 1598703456
Provider Name (Legal Business Name): ERICH GRAHAM RANDOLPH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 PARKWAY DR NE 300
ATLANTA GA
30312-1213
US

IV. Provider business mailing address

1072 W PEACHTREE ST NW UNIT 77114
ATLANTA GA
30357-3016
US

V. Phone/Fax

Practice location:
  • Phone: 404-522-6569
  • Fax: 404-522-8265
Mailing address:
  • Phone: 404-300-2476
  • Fax: 404-250-8010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number021790
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number021790
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: