=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508155458
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDY DAVID KATZKE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2011
-----------------------------------------------------
Last Update Date | 03/31/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16TH STREET 1ST AVENUE DEPARTMENT OF PEDIATRICS
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-244-5737
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 96 WHITMAN ST
-----------------------------------------------------
City | HAWORTH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07641-1933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-244-5737
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 234285
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------