Healthcare Provider Details

I. General information

NPI: 1619126992
Provider Name (Legal Business Name): RANDOLPH SPECIALTY GROUP PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 N PARK ST
ASHEBORO NC
27203-5440
US

IV. Provider business mailing address

PO BOX 5418
ASHEBORO NC
27204-5418
US

V. Phone/Fax

Practice location:
  • Phone: 336-625-1007
  • Fax: 336-625-0350
Mailing address:
  • Phone: 336-625-2333
  • Fax: 336-625-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: MR. ROBERT SCOTT CLAUSER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 336-625-2333