Healthcare Provider Details

I. General information

NPI: 1144320052
Provider Name (Legal Business Name): RANDOLPH MEDICAL PRACTICES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1847 SW BARNETT WAY
LAKE CITY FL
32025-6957
US

IV. Provider business mailing address

1847 SW BARNETT WAY
LAKE CITY FL
32025-6957
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-1440
  • Fax: 386-758-5628
Mailing address:
  • Phone: 386-755-1440
  • Fax: 386-758-5628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME46235
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME51982
License Number StateFL

VIII. Authorized Official

Name: TOMMY LAVAUGHN RANDOLPH
Title or Position: MD
Credential:
Phone: 386-755-1440