MEDICARE: FREEMAN RANDOLPH JACKSON M.D.

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	2085R0202X	Diagnostic Radiology Physician	22747	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	300085677	OTHER	NC	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1600271	OTHER	NC	UNITED HEALTHCARE
2	23519	OTHER	NC	PARTNERS
3	45552	OTHER	NC	BLUE CROSS BLUE SHIELD
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	73479	OTHER	NC	MEDCOST

General Provider Information

NPI Number	:	1235112178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREEMAN RANDOLPH JACKSON M.D.

Provider Business Mailing Address
First Line	:	1331 N ELM ST
Second Line	:	SUITE 200
City	:	GREENSBORO
State	:	NC
Zip	:	27401-6302
Country	:	US
Telephone Number	:	336-274-9617
Fax Number	:	336-482-2177

Provider Business Practice Location Address
First Line	:	1331 N ELM ST
Second Line	:	SUITE 200
City	:	GREENSBORO
State	:	NC
Zip	:	27401-6302
Country	:	US
Telephone Number	:	336-274-9617
Fax Number	:	336-482-2177

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	10/15/2014

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Directions to “ FREEMAN RANDOLPH JACKSON M.D.” Practice Location

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