MEDICARE: MARY KATHLEEN RANDALL

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	225100000X	Physical Therapist	P23461	NC

General Provider Information

NPI Number	:	1457028920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KATHLEEN RANDALL

Provider Business Mailing Address
First Line	:	4112 SPRING GARDEN ST
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-1684
Country	:	US
Telephone Number	:	336-294-0910
Fax Number	:

Provider Business Practice Location Address
First Line	:	4112 SPRING GARDEN ST
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-1684
Country	:	US
Telephone Number	:	336-294-0910
Fax Number	:

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

Provider Enumeration Date	:	08/24/2021
Last Update Date	:	11/26/2025

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Directions to “ MARY KATHLEEN RANDALL ” Practice Location

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