Basic Information
| Provider Information | |||||||||
| NPI: | 1790847978 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | DAVIS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3010 W AGUA FRIA FWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850273943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235375600 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 3420 S MERCY RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852970419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235375600 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 05/18/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 42715 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 42715 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 5550830001 | 01 | AZ | MEDICARE NSC SCW | OTHER | 5550830007 | 01 | AZ | MEDICARE NSC DV | OTHER | 5550830011 | 01 | AZ | MEDICARE NSC CENTRAL PHOENIX | OTHER | 5550830012 | 01 | AZ | MEDICARE NSC SPINE CENTER | OTHER | 5550830003 | 01 | AZ | MEDICARE NSC PEORIA | OTHER | 521790 | 05 | AZ | MEDICAID | 5550830010 | 01 | AZ | MEDICARE NSC GILBERT | OTHER |