Healthcare Provider Details

I. General information

NPI: 1205904950
Provider Name (Legal Business Name): RANDY J. GEORGEMILLER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E HOSPITAL RD ROOM 13A-10
FORT GORDON GA
30905-5650
US

IV. Provider business mailing address

300 E HOSPITAL RD ROOM 13A-10
FT GORDON GA
30905-5650
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-3143
  • Fax:
Mailing address:
  • Phone: 706-787-3143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY003859
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-003110
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: