Provider Demographics
NPI:1508896903
Name:CORDLE, RANDOLPH J (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:J
Last Name:CORDLE
Suffix:
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:PO BOX 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-355-2171
Mailing Address - Fax:704-355-5736
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-2171
Practice Address - Fax:704-355-5736
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200501146207P00000X
IN01041556A207P00000X
NC2005-01146207PP0204X, 2080P0204X, 2085U0001X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC140JJOtherNCBCBS
SCN46005Medicaid
NC5900951Medicaid
NC140JJOtherNCBCBS
NCG23880Medicare UPIN
NCP00382319Medicare PIN
SCN46005Medicaid