Provider Demographics
NPI:1053522045
Name:HEINZEL, RANDOLPH P (MD)
Entity type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:P
Last Name:HEINZEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1991 SPROUL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3518
Mailing Address - Country:US
Mailing Address - Phone:610-325-1350
Mailing Address - Fax:610-325-1357
Practice Address - Street 1:1991 SPROUL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3518
Practice Address - Country:US
Practice Address - Phone:610-325-1350
Practice Address - Fax:610-325-1357
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD431692207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA23-2359401OtherMLHC GROUP TIN
PA113215HK1Medicare PIN