Healthcare Provider Details

I. General information

NPI: 1134860653
Provider Name (Legal Business Name): ZACHARY ANIL RANDOLPH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E MEDICAL CENTER DR SPC B1-380
ANN ARBOR MI
48109-5000
US

IV. Provider business mailing address

PO BOX 980257
RICHMOND VA
23298-0257
US

V. Phone/Fax

Practice location:
  • Phone: 734-232-6008
  • Fax:
Mailing address:
  • Phone: 804-828-9783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301513460
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: