=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316148547
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRION VINCENT RANDOLPH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2007
-----------------------------------------------------
Last Update Date | 04/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1265 UNION AVENUE 2 SHORB TOWER
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-478-2211
-----------------------------------------------------
Fax | 901-478-2215
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1000, DEPT 457
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38148-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-275-3662
-----------------------------------------------------
Fax | 901-271-0155
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 81551
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number | 44535
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RH0000X
-----------------------------------------------------
Taxonomy Name | Hematology (Internal Medicine) Physician
-----------------------------------------------------
License Number | 44535
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 44535
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------