Healthcare Provider Details

I. General information

NPI: 1689677882
Provider Name (Legal Business Name): JOHN RANDOLPH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 10/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 LIBERTY BLVD
LIBERTY SC
29657-1641
US

IV. Provider business mailing address

PO BOX 919
PICKENS SC
29671-0919
US

V. Phone/Fax

Practice location:
  • Phone: 864-843-8500
  • Fax: 864-843-5634
Mailing address:
  • Phone: 864-897-8277
  • Fax: 864-878-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35074072
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24613
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: