Basic Information
| Provider Information | |||||||||
| NPI: | 1669453098 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | WHITESIDE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1222 TROTWOOD AVE | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384016436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313803033 | ||||||||
| FaxNumber: | 9313883401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 TROTWOOD AVE | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384016436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313803033 | ||||||||
| FaxNumber: | 9313883401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | MD11721 | TN | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3033757 | 05 | TN | MEDICAID |