Provider Demographics
NPI:1003873456
Name:PROVOST, RANDALL (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:PROVOST
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 1:98 DOCTORS DR
Mailing Address - Street 2:STE 200
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-4501
Mailing Address - Country:US
Mailing Address - Phone:828-586-8971
Mailing Address - Fax:828-586-4083
Practice Address - Street 1:98 DOCTORS DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-4501
Practice Address - Country:US
Practice Address - Phone:828-586-8971
Practice Address - Fax:828-586-4083
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32835207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7969355Medicaid
NCC86071Medicare UPIN
NC209737Medicare ID - Type Unspecified