MEDICARE: THE SOUTHEAST ASTHMA AND ALLERGY CENTER PC

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	207KA0200X	Allergy Physician	0034412	GA

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

General Provider Information

NPI Number	:	1295012631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SOUTHEAST ASTHMA AND ALLERGY CENTER PC

Provider Business Mailing Address
First Line	:	511 GORDON AVE
Second Line	:
City	:	THOMASVILLE
State	:	GA
Zip	:	31792-6645
Country	:	US
Telephone Number	:	229-226-5616
Fax Number	:	229-226-7132

Provider Business Practice Location Address
First Line	:	2804 REMINGTON GREEN CIR STE 1
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-8707
Country	:	US
Telephone Number	:	850-656-6269
Fax Number	:	850-877-5270

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	RANDOLPH AUGUSTUS MALONE IV
Credential	:	MD
Telephone Number	:	850-656-6269

Provider Enumeration Date	:	11/14/2011
Last Update Date	:	08/31/2022

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Directions to “THE SOUTHEAST ASTHMA AND ALLERGY CENTER PC ” Practice Location

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