Provider Demographics
NPI:1053583575
Name:RANDY L WARREN MD PLLC
Entity type:Organization
Organization Name:RANDY L WARREN MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-766-6666
Mailing Address - Street 1:4501 MACCORKLE AVE SW
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1444
Mailing Address - Country:US
Mailing Address - Phone:304-766-6666
Mailing Address - Fax:304-766-0999
Practice Address - Street 1:4501 MACCORKLE AVE SW
Practice Address - Street 2:SUITE 202
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1444
Practice Address - Country:US
Practice Address - Phone:304-766-6666
Practice Address - Fax:304-766-0999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV218272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002129Medicaid
WV4162851Medicare PIN
WV3810002129Medicaid