Healthcare Provider Details

I. General information

NPI: 1629868559
Provider Name (Legal Business Name): ADAM M RANDAZZO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 PINE GROVE AVE
PORT HURON MI
48060-3511
US

IV. Provider business mailing address

2294 ZINK RD APT 11
BEAVERCREEK OH
45324-6216
US

V. Phone/Fax

Practice location:
  • Phone: 810-987-5000
  • Fax:
Mailing address:
  • Phone: 586-894-2457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: