Basic Information
| Provider Information | |||||||||
| NPI: | 1083692453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALICOTT | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 344 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271020344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
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| Practice Location | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 08/23/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 200000741 | NC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | 200000741 | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 36495 | 01 | NC | PARTNERS | OTHER | 89126RJ | 05 | NC | MEDICAID | 126RJ | 01 | NC | BLUE CROSS | OTHER | 5069608 | 01 | NC | AETNA | OTHER | 9801180000 | 05 | WV | MEDICAID | 98162 | 01 | NC | MEDCOST | OTHER | 050086124 | 01 | RR MEDICARE | OTHER | Q0074C | 05 | SC | MEDICAID | 7300263 | 05 | VA | MEDICAID |