Healthcare Provider Details

I. General information

NPI: 1497815120
Provider Name (Legal Business Name): RANDOLPH MEDICAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 US HWY 431
ROANOKE AL
36274
US

IV. Provider business mailing address

PO BOX 625 965 US HWY 431
ROANOKE AL
36274-0625
US

V. Phone/Fax

Practice location:
  • Phone: 334-863-2141
  • Fax: 334-863-8733
Mailing address:
  • Phone: 334-863-2141
  • Fax: 334-863-8733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO-436
License Number StateAL

VIII. Authorized Official

Name: RUSSELL D PETERSON
Title or Position: PRESIDENT
Credential: DO
Phone: 334-863-2141