| Randolph Medical Practices Pa | |
|
1847 Sw Barnett Way Lake City FL 32025-6957 | |
| (386) 755-1440 | |
| (386) 758-5628 |
| Full Name | Randolph Medical Practices Pa |
|---|---|
| Speciality | Family Medicine |
| Location | 1847 Sw Barnett Way, Lake City, Florida |
| Authorized Official Name and Position | Tommy Lavaughn Randolph (MD) |
| Authorized Official Contact | 3867551440 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Randolph Medical Practices Pa 1847 Sw Barnett Way Lake City FL 32025-6957 Ph: (386) 755-1440 | Randolph Medical Practices Pa 1847 Sw Barnett Way Lake City FL 32025-6957 Ph: (386) 755-1440 |
| NPI Number | 1144320052 |
|---|---|
| Provider Enumeration Date | 09/22/2006 |
| Last Update Date | 10/31/2018 |
| Medicare PECOS PAC ID | 3779763503 |
|---|---|
| Medicare Enrollment ID | O20110210000477 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1144320052 | NPI | - | NPPES |
| 256113100 | Medicaid | FL | |
| 38690 | Other | FL | BCBS GROUP NUMBER |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | ME46235 (Florida) | Primary |
| 208000000X | Pediatrics | ME51982 (Florida) | Secondary |
| Provider Name | Tommy L Randolph |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1992805881 PECOS PAC ID: 9537294350 Enrollment ID: I20110223000908 |
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