Basic Information
| Provider Information | |||||||||
| NPI: | 1508896903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORDLE | ||||||||
| FirstName: | RANDOLPH | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601372 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043552171 | ||||||||
| FaxNumber: | 7043555736 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 BLYTHE BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043552171 | ||||||||
| FaxNumber: | 7043555736 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 200501146 | NC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 01041556A | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PP0204X | 2005-01146 | NC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 2080P0204X | 2005-01146 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 2085U0001X | 2005-01146 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 207P00000X | 2005-01146 | NC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 140JJ | 01 | NC | NCBCBS | OTHER | N46005 | 05 | SC | MEDICAID | 5900951 | 05 | NC | MEDICAID |