Provider Demographics
NPI:1942302021
Name:DRYE, RANDALL G (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:G
Last Name:DRYE
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 1:1910 BLANDING ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3520
Mailing Address - Country:US
Mailing Address - Phone:803-256-4107
Mailing Address - Fax:
Practice Address - Street 1:1910 BLANDING ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3520
Practice Address - Country:US
Practice Address - Phone:803-256-4107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18519207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT27593Medicaid
SCT27593Medicaid
SCG488261661Medicare PIN
SC5624960001Medicare NSC