MEDICARE: DR. FREDERICK 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	MD419725	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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154388445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FREDERICK RANDOLPH MD

Provider Business Mailing Address
First Line	:	1020 SANSOM ST
Second Line	:	SUITE 239
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-5002
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 SANSOM ST
Second Line	:	SUITE 239
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-5002
Country	:	US
Telephone Number	:	215-955-6844
Fax Number	:	215-955-2526

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

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	12/09/2014

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