Healthcare Provider Details

I. General information

NPI: 1619022779
Provider Name (Legal Business Name): RANDOLPH SPECIALTY GROUP PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SUNSET AVE
ASHEBORO NC
27203-5304
US

IV. Provider business mailing address

PO BOX 5418
ASHEBORO NC
27204-5418
US

V. Phone/Fax

Practice location:
  • Phone: 336-626-4328
  • Fax: 336-625-9941
Mailing address:
  • Phone: 336-625-2333
  • Fax: 336-625-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License NumberAS0054
License Number StateNC

VIII. Authorized Official

Name: ROBERT SCOTT CLAUSER
Title or Position: PRESIDENT
Credential:
Phone: 336-625-2333