MEDICARE: MR. RANDOLPH IRVIN AUSTIN JR.

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	101YA0400X	Addiction (Substance Use Disorder) Counselor		MD

General Provider Information

NPI Number	:	1548781511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDOLPH IRVIN AUSTIN JR.

Provider Business Mailing Address
First Line	:	PO BOX 980
Second Line	:
City	:	PRINCE FREDERICK
State	:	MD
Zip	:	20678-0980
Country	:	US
Telephone Number	:	410-535-3079
Fax Number	:	410-535-2220

Provider Business Practice Location Address
First Line	:	3819 HARBOR RD UNIT 103
Second Line	:
City	:	CHESAPEAKE BEACH
State	:	MD
Zip	:	20732-3110
Country	:	US
Telephone Number	:	410-286-0547
Fax Number	:	410-286-8950

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

Provider Enumeration Date	:	06/29/2017
Last Update Date	:	06/29/2017

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