Healthcare Provider Details

I. General information

NPI: 1467457424
Provider Name (Legal Business Name): ROBERT D RANDALL JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1665 HERLONG CT SUITE A
ROCK HILL SC
29732-1193
US

IV. Provider business mailing address

1665 HERLONG CT SUITE A
ROCK HILL SC
29732-1193
US

V. Phone/Fax

Practice location:
  • Phone: 803-329-8500
  • Fax: 803-329-8511
Mailing address:
  • Phone: 803-329-8500
  • Fax: 803-329-8511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number10864
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number20949
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: