=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134860653
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZACHARY ANIL RANDOLPH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2022
-----------------------------------------------------
Last Update Date | 06/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 E MEDICAL CENTER DR SPC B1-380
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48109-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-232-6008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 980257
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23298-0257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-828-9783
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 4301513460
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------