MEDICARE: RANDOLPH MEDICAL PRACTICES PA

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	208000000X	Pediatrics Physician	ME51982	FL
2	207Q00000X	Family Medicine Physician	ME46235	FL

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	38690	OTHER	FL	BCBS GROUP NUMBER

General Provider Information

NPI Number	:	1144320052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDOLPH MEDICAL PRACTICES PA

Provider Business Mailing Address
First Line	:	1847 SW BARNETT WAY
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-6957
Country	:	US
Telephone Number	:	386-755-1440
Fax Number	:	386-758-5628

Provider Business Practice Location Address
First Line	:	1847 SW BARNETT WAY
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-6957
Country	:	US
Telephone Number	:	386-755-1440
Fax Number	:	386-758-5628

Authorized Official
Title or Position	:	MD
Name	:	TOMMY LAVAUGHN RANDOLPH
Credential	:
Telephone Number	:	386-755-1440

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	10/31/2018

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Directions to “RANDOLPH MEDICAL PRACTICES PA ” Practice Location

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