Healthcare Provider Details

I. General information

NPI: 1629599931
Provider Name (Legal Business Name): DAVID THOMAS RANDOLPH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MEDICAL PARK, STE 400 CHILDREN'S HOSPITAL OUTPATIENT CENTER
COLUMBIA SC
29203
US

IV. Provider business mailing address

14 MEDICAL PARK, STE 400 CHILDREN'S HOSPITAL OUTPATIENT CENTER
COLUMBIA SC
29203
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6155
  • Fax: 803-434-6979
Mailing address:
  • Phone: 803-434-6155
  • Fax: 803-434-6979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL40998
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: