Healthcare Provider Details

I. General information

NPI: 1407125594
Provider Name (Legal Business Name): GAYLE JORDAN-RANDOLPH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2011
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 SAINT PAUL ST APT 2
BALTIMORE MD
21202-6512
US

IV. Provider business mailing address

920 SAINT PAUL ST SUITE 2
BALTIMORE MD
21202-2423
US

V. Phone/Fax

Practice location:
  • Phone: 410-727-4663
  • Fax:
Mailing address:
  • Phone: 410-727-4663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberD44078
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD44078
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberD44078
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: