MEDICARE: MR. RANDY C MAYERSON M.T.

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	247200000X	Other Technician		MI

General Provider Information

NPI Number	:	1578525093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDY C MAYERSON M.T.

Provider Business Mailing Address
First Line	:	1311 MAUREEN AVE
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-2934
Country	:	US
Telephone Number	:	248-545-6963
Fax Number	:

Provider Business Practice Location Address
First Line	:	1311 MAUREEN AVE
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-2934
Country	:	US
Telephone Number	:	248-545-6963
Fax Number	:

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

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	07/08/2007

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