Provider Demographics
NPI:1538684113
Name:RANDOLPH SPECIALTY GROUP PRACTICE
Entity Type:Organization
Organization Name:RANDOLPH SPECIALTY GROUP PRACTICE
Other - Org Name:CENTRAL CAROLINA SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
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 1:132 W MILLER ST STE C
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-4775
Practice Address - Country:US
Practice Address - Phone:336-626-3203
Practice Address - Fax:336-626-3230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-04
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1629375951Medicaid