MEDICARE: RANDALL CRUM INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1174663306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDALL CRUM INC.

Provider Business Mailing Address
First Line	:	11706 MERCY BLVD
Second Line	:	BLDG. 4
City	:	SAVANNAH
State	:	GA
Zip	:	31419-1751
Country	:	US
Telephone Number	:	912-927-5141
Fax Number	:	912-927-4441

Provider Business Practice Location Address
First Line	:	11706 MERCY BLVD
Second Line	:	BLDG. 4
City	:	SAVANNAH
State	:	GA
Zip	:	31419-1751
Country	:	US
Telephone Number	:	912-927-5141
Fax Number	:	912-927-4441

Authorized Official
Title or Position	:	C.E.O.
Name	:	MR. RANDALL ANDREW CRUM
Credential	:
Telephone Number	:	912-927-5141

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	08/22/2020

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