Healthcare Provider Details

I. General information

NPI: 1114195468
Provider Name (Legal Business Name): RANDOLPH SPECIALTY GROUP PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 N BROAD ST
SEAGROVE NC
27341-8583
US

IV. Provider business mailing address

PO BOX 5418
ASHEBORO NC
27204-5418
US

V. Phone/Fax

Practice location:
  • Phone: 336-873-8045
  • Fax: 336-873-9074
Mailing address:
  • Phone: 336-625-2333
  • Fax: 336-625-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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