Provider Demographics
NPI:1477721785
Name:RANDOLPH SPECIALTY GROUP PRACTICE
Entity Type:Organization
Organization Name:RANDOLPH SPECIALTY GROUP PRACTICE
Other - Org Name:RANDOLPH HEALTH FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:CLAUSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-625-2333
Mailing Address - Street 1:PO BOX 5418
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27204-5418
Mailing Address - Country:US
Mailing Address - Phone:336-625-2333
Mailing Address - Fax:336-625-5511
Practice Address - Street 1:525 W SWANNANOA AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:27298-3136
Practice Address - Country:US
Practice Address - Phone:336-622-4850
Practice Address - Fax:336-622-4855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0248ROtherBCBS
NC5900588Medicaid
NC0248ROtherBCBS