Provider Demographics
NPI:1467457424
Name:RANDALL, ROBERT D JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:D
Last Name:RANDALL
Suffix:JR
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 1:1665 HERLONG CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1193
Mailing Address - Country:US
Mailing Address - Phone:803-329-8500
Mailing Address - Fax:803-329-8511
Practice Address - Street 1:1665 HERLONG CT
Practice Address - Street 2:SUITE A
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1193
Practice Address - Country:US
Practice Address - Phone:803-329-8500
Practice Address - Fax:803-329-8511
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10864208600000X
NC20949208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC108644Medicaid
297388OtherMAMSI
2073882OtherFIRST HEALTH
NC2277954Medicare ID - Type Unspecified
SCD99172Medicare UPIN
SC108644Medicaid