=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497832257
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RANDOLPH COMMUNITY CLINIC SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 S HIGH STREET
-----------------------------------------------------
City | RANDOLPH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-326-5060
-----------------------------------------------------
Fax | 920-326-5061
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 504 S HIGH ST PO BOX 101
-----------------------------------------------------
City | RANDOLPH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53956-1499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-326-5060
-----------------------------------------------------
Fax | 920-326-5061
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MELISSA ELAINE LUCARELLI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 920-326-5060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 36988020
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------