Provider Demographics
NPI:1295012631
Name:THE SOUTHEAST ASTHMA AND ALLERGY CENTER PC
Entity type:Organization
Organization Name:THE SOUTHEAST ASTHMA AND ALLERGY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:AUGUSTUS
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:850-656-6269
Mailing Address - Street 1:511 GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6645
Mailing Address - Country:US
Mailing Address - Phone:229-226-5616
Mailing Address - Fax:229-226-7132
Practice Address - Street 1:2804 REMINGTON GREEN CIR STE 1
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-8707
Practice Address - Country:US
Practice Address - Phone:850-656-6269
Practice Address - Fax:850-877-5270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0034412207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000465671AMedicaid
GAE62149Medicare UPIN