Healthcare Provider Details

I. General information

NPI: 1508007485
Provider Name (Legal Business Name): REESE W. RANDLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-0545
  • Fax: 336-716-9758
Mailing address:
  • Phone: 336-716-0545
  • Fax: 336-716-9758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number63348-20
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number50013
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: