Provider Demographics
NPI:1770607228
Name:SWACKHAMMER, RANDY L (MD)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:L
Last Name:SWACKHAMMER
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 1:2400 WAYNE MEMORIAL DR STE C
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-1750
Mailing Address - Country:US
Mailing Address - Phone:919-988-9674
Mailing Address - Fax:919-988-9676
Practice Address - Street 1:2400 WAYNE MEMORIAL DR STE C
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-1750
Practice Address - Country:US
Practice Address - Phone:919-988-9674
Practice Address - Fax:919-988-9676
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33315207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP01133879OtherRAILROAD MEDICARE PTAN
PA0012769800001Medicaid
PA0012769800001Medicaid
NCP01133879OtherRAILROAD MEDICARE PTAN