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General NPI Number Information
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NPI Number | 1114195468
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Entity Type | Organization
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Legal Business Name | RANDOLPH SPECIALTY GROUP PRACTICE
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Dates
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Enumeration Date | 02/20/2008
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Last Update Date | 02/21/2020
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Provider Practice Location Address
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Address Line | 514 N BROAD ST
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City | SEAGROVE
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State | NC
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Zip | 27341-8583
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Country | US
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Telephone | 336-873-8045
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Fax | 336-873-9074
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Provider Business Mailing Address
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Address Line | PO BOX 5418
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City | ASHEBORO
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State | NC
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Zip | 27204-5418
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Country | US
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Telephone | 336-625-2333
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Fax | 336-625-5511
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | ROBERT SCOTT CLAUSER
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Credential |
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Telephone | 336-625-2333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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