Provider Demographics
NPI:1609838606
Name:GARRIOTT, RANDALL OWEN (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:OWEN
Last Name:GARRIOTT
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 1:800 N FANT ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5708
Mailing Address - Country:US
Mailing Address - Phone:864-512-1335
Mailing Address - Fax:
Practice Address - Street 1:800 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5708
Practice Address - Country:US
Practice Address - Phone:864-512-1335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17792207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT18200Medicaid
SC1153Medicare PIN
SCT18200Medicaid