Provider Demographics
NPI:1154388445
Name:RANDOLPH, FREDERICK (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SANSOM ST
Mailing Address - Street 2:SUITE 239
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1020 SANSOM ST
Practice Address - Street 2:SUITE 239
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5002
Practice Address - Country:US
Practice Address - Phone:215-955-6844
Practice Address - Fax:215-955-2526
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD419725207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0100072Medicaid
PA1010267480005Medicaid
PA101026748Medicaid
PA1010267480005Medicaid
080940Medicare ID - Type Unspecified
NJ0100072Medicaid