MEDICARE: FREDERICK WILLIAM RANDOLPH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	D0019085	MD
2	207P00000X	Emergency Medicine Physician	MD447333	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	10433266	OTHER		CAQH

General Provider Information

NPI Number	:	1033155247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDERICK WILLIAM RANDOLPH MD

Provider Business Mailing Address
First Line	:	2607 RHAWN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-3038
Country	:	US
Telephone Number	:	215-333-0304
Fax Number	:	215-333-1402

Provider Business Practice Location Address
First Line	:	2607 RHAWN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-3038
Country	:	US
Telephone Number	:	215-333-0304
Fax Number	:	215-333-1402

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	07/09/2019

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