Provider Demographics
NPI:1235208125
Name:JOHN RANDOLPH SURGEONS LLC
Entity Type:Organization
Organization Name:JOHN RANDOLPH SURGEONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-237-7760
Mailing Address - Street 1:411 W RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-2938
Mailing Address - Country:US
Mailing Address - Phone:804-452-1647
Mailing Address - Fax:804-452-1649
Practice Address - Street 1:411 W RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2938
Practice Address - Country:US
Practice Address - Phone:804-452-1647
Practice Address - Fax:804-452-1649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1235208125Medicaid
VAC10038Medicare PIN
DF5836Medicare PIN