Healthcare Provider Details

I. General information

NPI: 1487641700
Provider Name (Legal Business Name): MARCUS EDDIE RANDALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE STREET DEPARTMENT OF RADIATION MEDICINE
LEXINGTON KY
40536
US

IV. Provider business mailing address

800 ROSE STREET DEPARTMENT OF RADIATION MEDICINE
LEXINGTON KY
40536
US

V. Phone/Fax

Practice location:
  • Phone: 859-257-7618
  • Fax: 859-257-7483
Mailing address:
  • Phone: 859-257-7618
  • Fax: 859-257-7483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number01042349A
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number40518
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: