Provider Demographics
NPI:1477558542
Name:KEITH, RANDALL SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:SCOTT
Last Name:KEITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:104 ARARAT LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:PILOT MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:27041-8113
Mailing Address - Country:US
Mailing Address - Phone:336-786-7966
Mailing Address - Fax:336-786-1601
Practice Address - Street 1:104 ARARAT LONGHILL RD
Practice Address - Street 2:
Practice Address - City:PILOT MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:27041-8113
Practice Address - Country:US
Practice Address - Phone:336-786-7966
Practice Address - Fax:336-786-1601
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC39630207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8948063Medicaid
NC3966OtherPARTNERS MEDICARE
NCBCBS OF NCOtherBLUE CROSS BLUE SHIELD
NCB09474Medicare UPIN
NC8948063Medicaid