Basic Information
| Provider Information | |||||||||
| NPI: | 1275979361 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4111 1ST AVE | ||||||||
| Address2: | STE 3 | ||||||||
| City: | NITRO | ||||||||
| State: | WV | ||||||||
| PostalCode: | 251431345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042857200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 39 KENT RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317941697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293889393 | ||||||||
| FaxNumber: | 2293889855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2013 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 26527 | WV | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 84465 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.