Healthcare Provider Details

I. General information

NPI: 1619370905
Provider Name (Legal Business Name): RORY ERIC RANDALL CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE SEIDMAN CANCER CENTER RM 1830
CLEVELAND OH
44106-1716
US

IV. Provider business mailing address

11100 EUCLID AVE SEIDMAN CANCER CENTER RM 1830
CLEVELAND OH
44106-1716
US

V. Phone/Fax

Practice location:
  • Phone: 216-286-3826
  • Fax: 216-286-3864
Mailing address:
  • Phone: 216-286-3826
  • Fax: 216-286-3864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.305782-COA1
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCOA.16607-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: