Basic Information
| Provider Information | |||||||||
| NPI: | 1114938172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARD | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LAWRENCE | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705334786 | ||||||||
| Practice Location | |||||||||
| Address1: | 3215 MCCLURE BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300963223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783126200 | ||||||||
| FaxNumber: | 6783126226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 050992 | GA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000948109D | 05 | GA | MEDICAID | 000948109J | 05 | GA | MEDICAID | 12483797 | 01 | GA | MULTIPLAN | OTHER | 348302 | 01 | GA | WELLCARE | OTHER | 000948109F | 05 | GA | MEDICAID | 000948109H | 05 | GA | MEDICAID | 000948109M | 05 | GA | MEDICAID | 7651335 | 01 | GA | CARE IMPROVEMENT PLUS | OTHER | 1114938172 | 01 | GA | TRICARE CERTIFIED | OTHER | 582117020056 | 01 | GA | TRICARE CERTIFIED | OTHER | 000948109C | 05 | GA | MEDICAID | 52895966 | 01 | GA | BCBS | OTHER | 582117020002 | 01 | GA | TRICARE CERTIFIED | OTHER | 000948109K | 05 | GA | MEDICAID | 01344195 | 01 | GA | AMERIGROUP | OTHER | 000948109L | 05 | GA | MEDICAID | 000948109N | 05 | GA | MEDICAID | P01342975 | 01 | GA | PALMETTO GBA RAILROAD MEDICARE | OTHER | 0009481091 | 05 | GA | MEDICAID | 000948109E | 05 | GA | MEDICAID | 000948109O | 05 | GA | MEDICAID | 110029C003330 | 01 | GA | TRAILBLAZER HEALTH ENTERPRISES | OTHER | 7573710 | 01 | GA | CIGNA | OTHER |