Randall, Derrick Wade
Randall, Derrick Wade is an individual health care provider with primary practice located at 2145 Henry Tecklenburg Dr Ste 220 , Charleston SC 29414-5894. He recently has 2 registered licenses in different health care specialties including Allopathic & Osteopathic Physicians / Anesthesiology, Allopathic & Osteopathic Physicians / Pain Medicine. Allopathic & Osteopathic Physicians / Pain Medicine is his primary health care specialty. Randall, Derrick Wade can be contacted via phone (843) 723-8823.Contact Information
Primary practice address
2145 Henry Tecklenburg Dr Ste 220
Charleston SC 29414-5894
Phone: (843) 723-8823
Fax: (843) 606-8059
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Allopathic & Osteopathic Physicians / Anesthesiology | 207L00000X | 19659 | South Carolina |
| Allopathic & Osteopathic Physicians / Anesthesiology | 207L00000X | 050251 | Georgia |
| Allopathic & Osteopathic Physicians / Pain Medicine | 207LP2900X | 19659 | South Carolina |
| Allopathic & Osteopathic Physicians / Pain Medicine | 208VP0000X | 19659 | South Carolina |
Profile Details
| NPI number | 1699766758 |
|---|---|
| LBN Legal business name | Randall, Derrick Wade |
| Credentials | Doctor of Medicine (MD) |
| Entity | Individual |
| Sole proprietor 1 | No |
| Enumeration date | Oct 28th, 2005 |
| Last updated | Sep 4th, 2020 - about 4 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1699766758 | NPPES |
| South Carolina | Other | 19659 | SC LICENSE |
| South Carolina | MEDICAID | 196594 | SC LICENSE |
| South Carolina | MEDICAID | 000915967B | SC LICENSE |
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