Provider Demographics
NPI:1124104138
Name:SCOTT, RANDOLPH PATRICK (MD, PHARMD)
Entity type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:PATRICK
Last Name:SCOTT
Suffix:
Gender:M
Credentials:MD, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD
Mailing Address - Street 2:FL 2
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-271-2099
Practice Address - Street 1:600 ROE AVENUE, SUITE 1A
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1629
Practice Address - Country:US
Practice Address - Phone:607-737-4130
Practice Address - Fax:607-737-4530
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06186400208G00000X
NY198637208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02150434Medicaid
NJ8142505Medicaid
NJ8142505Medicaid