Healthcare Provider Details

I. General information

NPI: 1174580948
Provider Name (Legal Business Name): RANDY EARL EISENHUT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6551 CENTERVILLE BUSINESS PKWY STE 110
DAYTON OH
45459-2696
US

IV. Provider business mailing address

PO BOX 933432
CLEVELAND OH
44193-0039
US

V. Phone/Fax

Practice location:
  • Phone: 937-291-6850
  • Fax: 947-291-6896
Mailing address:
  • Phone: 937-641-3555
  • Fax: 937-641-4528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35058652E
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: