Basic Information
Provider Information | |||||||||
NPI: | 1538162953 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOUTHARD | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | N | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850182327 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029331814 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1919 E THOMAS RD | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850167710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029331213 | ||||||||
FaxNumber: | 6029331214 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2005 | ||||||||
LastUpdateDate: | 02/08/2018 | ||||||||
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 | 208000000X | 38022 | AZ | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2085R0202X | 38022 | AZ | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | J9359 | TX | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085P0229X | 38022 | AZ | Y |   | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
ID | Type | State | Issuer | Description | 335961 | 05 | AZ |   | MEDICAID | 134459001 | 05 | TX |   | MEDICAID |