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General NPI Number Information
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NPI Number | 1295012631
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Entity Type | Organization
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Legal Business Name | THE SOUTHEAST ASTHMA AND ALLERGY CENTER PC
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Dates
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Enumeration Date | 11/14/2011
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Last Update Date | 08/31/2022
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Provider Practice Location Address
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Address Line | 2804 REMINGTON GREEN CIR STE 1
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City | TALLAHASSEE
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State | FL
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Zip | 32308-8707
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Country | US
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Telephone | 850-656-6269
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Fax | 850-877-5270
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Provider Business Mailing Address
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Address Line | 511 GORDON AVE
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City | THOMASVILLE
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State | GA
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Zip | 31792-6645
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Country | US
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Telephone | 229-226-5616
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Fax | 229-226-7132
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Authorized Official
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Title or Position | PHYSICIAN
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Name | RANDOLPH AUGUSTUS MALONE IV
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Credential | MD
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Telephone | 850-656-6269
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207KA0200X
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Taxonomy Name | Allergy Physician
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License Number | 0034412
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License Number State | GA
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