MEDICARE: DR. MICHAEL C RANDALL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083X0100X	Occupational Medicine Physician	G37167	CA

General Provider Information

NPI Number	:	1487896767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL C RANDALL M.D.

Provider Business Mailing Address
First Line	:	4924 BALBOA BLVD, #107
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91316
Country	:	US
Telephone Number	:	310-601-4404
Fax Number	:

Provider Business Practice Location Address
First Line	:	4924 BALBOA BLVD # 107
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91316-3402
Country	:	US
Telephone Number	:	310-601-4404
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2009
Last Update Date	:	04/01/2009

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