Healthcare Provider Details

I. General information

NPI: 1477558542
Provider Name (Legal Business Name): RANDALL SCOTT KEITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 ARARAT LONGHILL RD
PILOT MOUNTAIN NC
27041-8113
US

IV. Provider business mailing address

104 ARARAT LONG HILL RD
PILOT MOUNTAIN NC
27041-8113
US

V. Phone/Fax

Practice location:
  • Phone: 336-786-7966
  • Fax: 336-786-1601
Mailing address:
  • Phone: 336-786-7966
  • Fax: 336-786-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39630
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: