Basic Information
| Provider Information | |||||||||
| NPI: | 1417934902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDS | ||||||||
| FirstName: | ROSELAVENDER | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RICHARDS | ||||||||
| OtherFirstName: | ROSELAVENDER | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD INC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3420 E SHEA BLVD STE 200266 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850283345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809776000 | ||||||||
| FaxNumber: | 2482690631 | ||||||||
| Practice Location | |||||||||
| Address1: | 3420 EAST SHEA BLVD | ||||||||
| Address2: | STE 200 OFFICE 266 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809776000 | ||||||||
| FaxNumber: | 2482690631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 03/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 23096 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | AZ0702650 | 01 | AZ | BC BS OF AZ | OTHER | 318205 | 05 | AZ | MEDICAID |