Basic Information
Provider Information | |||||||||
NPI: | 1184652406 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RICHARDSON | ||||||||
FirstName: | SCOTT | ||||||||
MiddleName: | KENCHILOE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4555 OTTAWA PLACE | ||||||||
Address2: |   | ||||||||
City: | BOULDER | ||||||||
State: | CO | ||||||||
PostalCode: | 80303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034945588 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 605 PARFET ST | ||||||||
Address2: | # 103 | ||||||||
City: | LAKEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 802155576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037582800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2006 | ||||||||
LastUpdateDate: | 09/02/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 27137 | CO | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 01271378 | 05 | CO |   | MEDICAID | 26701316 | 05 | CO |   | MEDICAID |