Provider Demographics
NPI:1497815120
Name:RANDOLPH MEDICAL ASSOCIATES, PC
Entity type:Organization
Organization Name:RANDOLPH MEDICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:D
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:334-863-2141
Mailing Address - Street 1:PO BOX 625
Mailing Address - Street 2:965 US HWY 431
Mailing Address - City:ROANOKE
Mailing Address - State:AL
Mailing Address - Zip Code:36274-0625
Mailing Address - Country:US
Mailing Address - Phone:334-863-2141
Mailing Address - Fax:334-863-8733
Practice Address - Street 1:965 US HWY 431
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:AL
Practice Address - Zip Code:36274
Practice Address - Country:US
Practice Address - Phone:334-863-2141
Practice Address - Fax:334-863-8733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO-436207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH985Medicare ID - Type Unspecified
ALE26656Medicare UPIN