Basic Information
| Provider Information | |||||||||
| NPI: | 1497968366 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDS | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | BOONE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9800 SHELBYVILLE RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402232992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024298585 | ||||||||
| FaxNumber: | 8556567325 | ||||||||
| Practice Location | |||||||||
| Address1: | 3003 CHARLESTOWN XING | ||||||||
| Address2: | SUITE D | ||||||||
| City: | NEW ALBANY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471508302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129455653 | ||||||||
| FaxNumber: | 8556567325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 01071200A | IN | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207K00000X | 45401 | KY | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 201082460 | 05 | IN | MEDICAID | 7100209280 | 05 | KY | MEDICAID |