Provider Demographics
NPI:1497832257
Name:RANDOLPH COMMUNITY CLINIC SC
Entity Type:Organization
Organization Name:RANDOLPH COMMUNITY CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:LUCARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-326-5060
Mailing Address - Street 1:504 S HIGH ST
Mailing Address - Street 2:PO BOX 101
Mailing Address - City:RANDOLPH
Mailing Address - State:WI
Mailing Address - Zip Code:53956-1499
Mailing Address - Country:US
Mailing Address - Phone:920-326-5060
Mailing Address - Fax:920-326-5061
Practice Address - Street 1:504 S HIGH STREET
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:WI
Practice Address - Zip Code:53956
Practice Address - Country:US
Practice Address - Phone:920-326-5060
Practice Address - Fax:920-326-5061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36988020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32327000Medicaid
N96OtherDEAN HEALTH PLAN
CH8761OtherRAILROAD MEDICARE
=========016OtherBLUE CROSS
WI32327000Medicaid