MEDICARE: WALTER WATSON RANDOLPH III 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	207V00000X	Obstetrics & Gynecology Physician	35071310R	OH

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	:	1992700520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALTER WATSON RANDOLPH III MD

Provider Business Mailing Address
First Line	:	1417 KADERLY ST NW
Second Line	:
City	:	NEW PHILADELPHIA
State	:	OH
Zip	:	44663-1242
Country	:	US
Telephone Number	:	330-602-5678
Fax Number	:	330-602-9604

Provider Business Practice Location Address
First Line	:	1417 KADERLY ST NW
Second Line	:
City	:	NEW PHILADELPHIA
State	:	OH
Zip	:	44663-1242
Country	:	US
Telephone Number	:	330-602-5678
Fax Number	:	330-602-9604

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

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	03/01/2012

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