Provider Demographics
NPI:1730271602
Name:GOODROE, RANDALL NIX (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:NIX
Last Name:GOODROE
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 1:920 DOUG WHITE DR STE 510
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4183
Mailing Address - Country:US
Mailing Address - Phone:843-497-7772
Mailing Address - Fax:843-848-7530
Practice Address - Street 1:920 DOUG WHITE DR STE 510
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4183
Practice Address - Country:US
Practice Address - Phone:843-497-7772
Practice Address - Fax:843-848-7530
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23353207R00000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC383781722OtherPRACTICE TAX ID
SC233535Medicaid
SC233535Medicaid
SC233535Medicaid
SC57-0528030OtherPRACTICE TAX ID NUMBER
SCI41474Medicare UPIN