I

I - - Virginia Urology C Ryan Bames, M.D.

Gary B. Bokinsky, M.D.

Roberl 0. Brown, M.D.

Joseph A Concodora. M.D.

Eric P. Cote, M.D.

G. Bryan Duck, M.D.

David B Glazier, M.D.

Richard W. Graham, M.D.

Sam 0. Graham, Jr.. M.D.

Lonny S. Green, M D.

Isaac Koziol. M.D.

Eugene V. Kramolowsky 11, M.D.

Douglas H. Ludeman, Jr.. M.D.

James M. McMuW, M.D.

Wilson C. Merchant, 111, M.D.

David A. Miller, M.D.

Mark B. Monahan, M D.

William R. Morgan, M.D.

David P. Murphy, M.D.

Kinloch Nelson, M D.

RoberlT. Nelson, Jr.. M.D.

James E. RalliA. M 0.

Kent L. Rollins, M.D.

Charles A. Seabuly, M.D.

Anlhony M. Sliwinski, M.D.

Wllliam S Tunner, M.D.

Charles E. Wadsworlh. P.A

CHILDREN'S CENTER

John D. Edmondson, M.D.

Leon I Smith-Harrison, M.D.

Boyd H. Winslow, M.D.

Valre W. Welch, C.P.N.P.

LABORATORY

Dharam M. Ramnani. M.D.

William H.Atwill. M.D., Retired

Austin I. Dodson. Jr.. M.D., Retired

J. Edward Hill, M.D.. Retired

C.M. Kinloch Nelson, M.D., Retired

RICHMOND LOCATIONS

Hanover Medical Park

Monument Avenue

Stony Point Drive

West Broad Street

OTHER LOCATIONS

Colonial Heighls

Emporia

Hopewell

Tappahannock

Williamsburg

ADkIINISTRATION

9105 Stony Point Drive

Richmond, Virginia 23235

(804) 330-9105

BOO VA-UROLO

www.uro.com

December 6,2004

Mr. Bryan A. Parker, Health Physicist Division of Nuclear Materials Safety Nuclear Regulatory Commission Region 11 61 Forsyth Street SW, Ste. 23T85 Atlanta, GA 30303-8931 fjw~ ofo Re: License ##45-25582-01

Dear Mr. Parker:

This is to advise you that we wish to add to the above-referenced license an additional Authorized User. The user is Dr. David H. Randolph. I have enclosed his credentials for your review.

Thank you for taking care of this change to our license.

Sincerely,

Administrator

/cja

David Marcus Rartdolph, M.D. Dircctor, Radiation Oncology 27 $84 542: 15

PRJ3ENT POSITION:

DMECTOX, RADIATION ONCOLOGY ONCOLOGY & HEMATOLOGY ASSOC OF SW VA 1900 ELECTRIC KD

DECEMBER 3,000 -PRESENT

- SALEM, VIRGINIA 24153

July 1989-present MEDICAL DIRECTOR, Ft4Dk\TION ONCOLOGY DEPARTMENT

LEWIS-GALE MEDICAL CENTER SALEM, VIRGIN& 241 53 MEDICAL DIRECTOR NEW EWER VALLEY CANCER CAFS CEhTER PULASKT, VRGINU Hospital Conwittee Appointments. Member, bdiatiou Safety Committec, 1389-current Chairman, Radiation Safety Cornmktee, 19YO-Current Quality hiianagement Committee, Chairman Cancer Condtlee, 2000,1998 $1 997,1994,2993 Cancer Committee, 1989-currertt Cllairmm Quality Management Committee 1995- current Vice President Medical $taff 1997 Cmcer Liaison 1997-2002

LE W 1s-GALE FSJ3IONA.L CANCER CENTER

1 ,

arrw OF STAFF 1 993-200 I +

Community Activities: Roanoke County Lirtle 'I,eape Basketball Coach 1994-~urrcnt Rehabilitation Committee Chairmar,, Koanoke Unit American Cancer Society 1989-currcnt Anierican Cancer Society, Roanoke-Franklin Unit 1989-current Caw Spring Pony Tail Basketball League Coach 1994-rment Member, Salem Kotary Club 1Y89-1993 Board Member, First Union Rcgional Bank 50ard Member, Roanoke Symphony 1989- 1993 Cave Spring American Baseball League Coach 1994-current Chairmen of Board of Roanokr: Academy of Medicine 1396. i997, 1937- 1998 President Elect, 'Roanoke Academy Of Medicine 1997-1 998 Prcsicjtxkt, Roanoke Acadcmy Of Medicine 1999-2000 Medical Director FYousecdl Hospice 1997 to 2002 I W M N A L INFORMATION WAS REMOVED

BY NRCa NO COPY OF THIS INFORMATION WAS RETAINED BY THE NRC, I

Board hiember, Uni tad Way 198 9- cunert Delegate, Medical Society of Virginia 1991,1997,1998,1399 Director of Radiation Otmlogy lor Ortcology and Heiizatdogy Associates uf S.W. Virginia Miiltipte Spe&-E;i~g engagements on EARLY DETEC'I'TON, PREVENTION and TREATMENT OF CANCER, i 3 .

).I

Honors Bad Awards

1999 Recipient of Lane W. Adiuns Amrd: This award is given tiationally by the Anlerican . Cancer Society for recognition of irulovativt: m c l consistent excellcnce in providing

cnmpmhnate, skilled cxx and cuutisel to persoits with cancer and their fanamilios. He was the first physician in Virginia to receive this award This is the Highest tiward given by

the ,-&can Cancer Society.

2000 Recipient of Sharon H Ktrhfcnbccg Healthcare Service Award from Vjrgnia Breast G m c r Foundation.

LICENSE AND CFR.TZFICATII)NS:

1986 - Certified by the b m c a n Academy of Family Practice 1990 - Certified by thc American Board of Radiology 19x4 - Virginia License to practice Medicine and Surgery

MEDICAL COLIEGE OF VIRGMA Kichiiotid, Virginia Residency in Radiation Oncology, l986-June, 1989

Extracurricular Activities: 1986- 1989 - h s t w r o r for Schcd of Radiologic Technology

1986- 1,989 - Resident Reprcseatative fo I&sc Staff Camnittw Medical Cotlcge of Virginia

UNIVERSXTTY OF VTRGWLA HOSPITAT> Charlottesville, Virginia Residency in Family Practice, 19641986 Internship in Family Praclice, 1983-1984

Extra Curricul or Ax tivi ties:

Participant in many adult basketball ieagues, including Hoop-11-Up (division champion 1994 and 1996,) Richmond, Vireinia Woodworking

I

Norfolk, Virginis Doctor of Medicine, 1983

Honors and Awards:

Completed Medical School in 3 years, 1980-83

Recipient of the Brown Award; Scholuship for the student having overcome the most obstacles to get 10 medical school

VRGTNIA COMMONWEALTH UNIVERSTTY Richmond, Virginia Blrchelor of Science Degree in Etiology, 1980

Honors and Awards:

Cornplctcd Bachelors Degree in 3 years, 1978- 1980 Graduated Cum Laude

Extra Curriclilar Activities:

1980 - President, Beta Club, National Biological Honor Society 1980 - Honors Biology Enrollsx: Varsity Basketball Member Teniire Committee for the Department of Philosophy and Religious Studies

PAPERS AND PRBSENTAT1C)NS: 1

12/88 - "The Impact of Untreated Pelvic Lymph Nudes on Local Control and Sun4vnf in Carcinoma of the Prostate"; presented at tlk Endocurietherapy Society, Annual Meeting.

5/87 - "The Diagnosis and Managemait of Synovial Sarcoma", pmentcd at the MASRO meeting, Williamsburg, Virginia.

Personal:

BY NRC. NO COPY OF THIS INFORMATION WAS RETAINED BY THE NRC. 3

Office of Continuing Medica! Education P.6 , Box 80071 1

C%srlotittesvil!e, VA 229084.7 I 1 certifies that,

bas pa I-ticipa ted in the educational activity titled

and is awarded a maximurn of 7.75 ca#cgoT 1 credits towards (he AMA Physiciau's Recoynitinn Award

October f 1,2003 _I ." -

Gate __v_--

~ a m i ~ ~ n Curmw, mi- CME Coordinator

has participated in the Contin iring Medical Ediicntion ac fivity

“Lewis Gale Medical Center Cancer Conference”

January 6 - December 29,2003 and has earned 39 credit Hoiirs in Category I of the

Physician’s Recognition Award of the Americnn Medical Association

The Lewis-Gale CME Organization is accredited by the Medical Society of Virginia to sponsor continuing medical education for physicians.

SENT

EV:

HD

LA

SER

JET

3153

; 77

6473

8 ;

FEB-

24-0

4 11 :

dSA

M;

PAG

E 11

:2a

TO:

SLTHJECT:

F.ncloscd i s a conrrpulerkcd CiME .Report of the Caregmy 1 continuing mcdi.cd education activities our nxords indicate you attmded from Januasy I , 2003 through December 311 2O03 sponsored by Cwiliun IIedtb Sjls-tern CMJ;, Yropm. The repit kt.ts thc &tcs ~f the cctivity? r? I

cock for the activity t-vpe, the title of each activity, andmrnbtz of credits prwided. Activities sponsored by other CP4E Accredited Agencies you m y have attended m r r o t a~mu~(lt un .h$ p ~ e . An o~iginal ~ Y Q W report h s been forcvudcd to Bedkird Memorial Hospital.

Please review your report, Uyoa note inaccuracies or have qticstiians, pIrase all me-

Carfiion Health System Medical Staff Y 4 ,.

2003 Csnthnuirtg Medical Education Report ,&& , 6 " . I 7: ; :.* $qFKf.. -" ?.,. .")' 1;; I

..,'. .I.. ,

f naTk )U.l,

LindaM. Wells, CMI! Coordinator I

Carilion Health System Carilion Roanoke Memorial Hospital PO Box 13367 ..,' Roanoke, VA 24033 Tele: 540-931-8589 Fax: 540-916-5323

/'

Enclosures

his report in your per fde for use in credentialing, reappointments, etc. Request for extra copies of CIHE Reports will1 cost $5.00 per page, and must be sub&tted b y Ietter, ta my attention, with. a

-.

27w Randolph, Davld DATE r m 10PIC CHEDITB

1

1

..1/3/2003 WCCH T'drnor ConferencslCasa Presentations & OisCUSSion

5f ?EO03 WCCH Tumor ConferencdCass Presentations b Discussion

I 10/2'2003 WCCH 'Tumor ConferencelCase Presentations & BiScrrssiul7 pii-iEaCnsdil----T7

1

Cariion Healfh System la accredited by The Medicat Saclaty of Virginla lo provide contihrhg medical education far physicians. ACCME ID# 4802728

ACLSIATLSNALS:'NRRCPR Breast Biopsy Correlation Cofirence Breast Pre-Treatment Plari ig Conference Cardiac Cath Confhnce Conversations in Ethjcs Cold Alert Review Conference GYN-Oncology C!onfhrenl;e Head & Neck Oncology Conference Joint-Sponsored Conference Joint-Sponsored Perinatal Education Conference Mahidity & Mortality Conference Oncology C o d a m Orthopedic Conference Pediatric Acute Cam Conibrence Pediatrk Grand Rounds f'sychiatdc, G r a d Reunds Pediatric Case Cortference Pediatric OncoIogy Confie rence R e d Confkrence Sleep Disorder Confkrencs Special Conference Surgical Conference Surgical Grand Rounds Thoracic Oncology Cdemnce Topics in Clinical Medicine Vucular Conference

Bedford Memorial Hospitd Franklin Memorial Hospital Giles Memorid Hospital New m e r Valley Medica! Center Saint m a n s Psychiatric Ffospital Soutkidr, Community Hospital Wythe County Gonununity Hospkd

Continuing Medicrl Education Program coNkrE.mCIE1 CODES

LST BBC BTC ccc CE C3L CY0 H&N 105 JOSPER M&M ONC ORT PAC PGR FSGR PMM POC E C SDC SPC SUR SGR TOC TCM V-AC

CBMH C k M I CGMC-l ' CNRVMC CSAPH SCH WCCH

I .

I/ I Continuing hAedical Education Program

THIS IS TO ACKNOWLEDGE THAT I I ;

1 Ill -.-- Name Ill

A7TEN DEI3

1VVytho Csunty Community Hospital Tumor Confweme -c

rwe

--_c November $? 2Q03

Carilion Health System 1s accredited by The Medical Society of Virginia to Provide continuing medicat educatlan for physicians, ACCME ID# 4002728,

Garilion Health System designates this educational activity for a maxlmum ~ f :

Dare

4 ~ - n ~ r y 1 Medical Society of Virginia (fvlembership requirement & Physician's

vcrrry~ry -I American Medical Association (Physician's Recognition Award) 111 A m > d m n Academy of Family Physician's. Prescribed -_ Elective nitiori Award)

' -* -- -_-I_-

License Lookup Page 1 of 1

Public Information System I

(Download licensee. information I DHP Home Paee) Last updated on 07/08/2004

Search Result! Your search returns 1 record.

License No. Occupation Name Address of Record Initial License Expire Date Subject to a

0101036962 MEDICINE & SURGERY DAVID M RANDOLPH Salem, VA 24153 0711 21 1984 0713 112006 NO (Specialization) (License Status) Proceeding .x

Current Active

* "Yes" under "Subject to a Proceeding" means that the licensee has been subject to aproceeding and that more information may be obtained by contacting the appropriate board. A "No" means that the licensee has not been subject to a proceeding.

Back to License Lookup \

http://www.vipnet.org/dhp/cgi-bin/searchqublicdb.cgi 7/8/2004 4

... . .. ..

PERSONAL INFORMATION WAS REMOVED BY kRC. I40 COPY OF THIS INFORMATION

WAS RETAINED BY THE NRC.

MCV Campus

Health Svstem MCV Hospitals and’Physicians June 25, 2004

CCVS, Incorporated Noni Ledford Credentials Coordinator 1200 East Clay Street Richmcfid, va 212 19

Fax: (804) 643-2291

Attn: Noni Ledford

Graduate Medical Education

West Hospital 1200 East Broad Street PO. Box 980257 Richmond, Virginia 23298-0257

804 828-9783 Fax: 804 828-561 3 TOO: 1-800-828-1 120

This is to certify that David H. Randolph, M.D. has satisfactorily completed the following at the Medical College of Virginia Hospitals:

INTERNSHIP in the DEPARTMENT of

DATE:

RESIDENCY in the DEPARTMENT of: Radiation Oncology

DATE: 7/0 1 / 8 6-6/ 3 OJ8 9

FELLOWSHIP in the DEPARTMENT of

DATE:

Cord i a1 1 y,

Mary Alice O’Donnell, Ph.D. Director of Graduate Medical Education

An Equal Op!xHlunilylAfllrmarae Acricn UnivelsirV

BonrdCerti fiedDocs Page 1 of 1

ABMs Primary Source Data

AMERICAN BOARD OF FAMILY PRACTICE CERTIFICATION(S1: Family Practice 07jli/1986 - 12/31/1993 AMERICAN BOARD OF RADIOLQGY CERTIFICATION (S) : Radiation Oncology 1991*

*Lifetime certification in this certificate.

Diplomate Self Reported Data

EDUCATION : Eastern Va Med Sch, Norfolk (1983, MD)

CAREER: Training Appointments: Int, U Va, Lynchburg, VA (1983 - 1984) Res, Family Practice, U Va, Lynchburg, VA Res, Radiological Oncology, Med Coll Va, R

TYPE OF PRACTICE: Full Time Priv Prac Solo

Abbreviation ExDlanation

1984 - 986) hmond, VA (1986 - 1989)

back%) search results 1

Terms and Conditions I Copvriqht 0 2004 Elsevier,

PERSONAL INFORMATION WAS REMOVED BY NRC. NO COPY OF THJS INFORMATION

WAS RETAINED BY THE NRC.

3 3

BETWEEN:

License Fee Management Branch, ARM

Regional Licensing Sections and

.. ..

LICENSE FEE TRANSMITTAL

A. REGION z

(FOR LFMS USE) INFORMATION FROM LTS

1. APPLICATION ATTACHED ApplicantILicensee: VIRGINIA UROLOGY CENTER Received Date: 20041217 Docket No: 3 0 3 5 9 4 1 Control No.: 136152

Action Type: Amendment License No.: 45-25582-01

Program Code: 02200 Status Code: 0 Fee Category: IC Exp. Date: 20120430 Fee Comments: Decom Fin Assur Reqd: N ............................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2 . FEE ATTACHED Amount : Check No. :

3 . COMMENTS

Signed

B. LICENSE FEE MANAGEMENT BRANCH (Check when milestone 03 is entered /-/)

1. Fee Category and Amount:

2 . Correct Fee Paid. Application may be processed for: Amendment Renewal License

3. OTHER

Signed Date