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General NPI Number Information
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NPI Number | 1144320052
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Entity Type | Organization
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Legal Business Name | RANDOLPH MEDICAL PRACTICES PA
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Dates
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Enumeration Date | 09/22/2006
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Last Update Date | 10/31/2018
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Provider Practice Location Address
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Address Line | 1847 SW BARNETT WAY
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City | LAKE CITY
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State | FL
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Zip | 32025-6957
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Country | US
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Telephone | 386-755-1440
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Fax | 386-758-5628
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Provider Business Mailing Address
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Address Line | 1847 SW BARNETT WAY
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City | LAKE CITY
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State | FL
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Zip | 32025-6957
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Country | US
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Telephone | 386-755-1440
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Fax | 386-758-5628
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Authorized Official
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Title or Position | MD
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Name | TOMMY LAVAUGHN RANDOLPH
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Credential |
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Telephone | 386-755-1440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME51982
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME46235
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License Number State | FL
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