Provider Demographics
NPI:1275591992
Name:ROANOKE HEALTHCARE AUTHORITY
Entity Type:Organization
Organization Name:ROANOKE HEALTHCARE AUTHORITY
Other - Org Name:RANDOLPH MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-863-4111
Mailing Address - Street 1:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:AL
Mailing Address - Zip Code:36274-0670
Mailing Address - Country:US
Mailing Address - Phone:334-863-4111
Mailing Address - Fax:334-863-5427
Practice Address - Street 1:59928 HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:AL
Practice Address - Zip Code:36274-2410
Practice Address - Country:US
Practice Address - Phone:334-863-4111
Practice Address - Fax:334-863-5427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALH5601282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALHOS0098HMedicaid
ALHOS1303HMedicaid
AL01045OtherBCBS OF AL
ALK745Medicare PIN
ALHOS0098HMedicaid