Healthcare Provider Details

I. General information

NPI: 1336295476
Provider Name (Legal Business Name): RANDOLPH OTOLARYNGOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 ROUTE 10
RANDOLPH NJ
07869
US

IV. Provider business mailing address

400 ROUTE 10 WEST
RANDOLPH NJ
07869
US

V. Phone/Fax

Practice location:
  • Phone: 973-839-1003
  • Fax: 973-839-3653
Mailing address:
  • Phone: 973-839-1003
  • Fax: 973-839-3653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number25MA03981000
License Number StateNJ

VIII. Authorized Official

Name: MICHAEL P STEIN
Title or Position: DR OF MEDICINE
Credential: MD
Phone: 973-839-1003