Basic Information
| Provider Information | |||||||||
| NPI: | 1669619441 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARK D RICHARDSON MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 E MANSION ST STE 1E | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490681167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2697813938 | ||||||||
| FaxNumber: | 2697818364 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 E MANSION ST STE 1E | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490681167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2697813938 | ||||||||
| FaxNumber: | 2697818364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2009 | ||||||||
| LastUpdateDate: | 06/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | RICHARDSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2697813938 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301047635 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2895802 | 05 | MI | MEDICAID |