Provider Demographics
NPI:1013006584
Name:RICHARDSON, TOMMIE MACK (MD)
Entity Type:Individual
Prefix:
First Name:TOMMIE
Middle Name:MACK
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 S COBB DR
Mailing Address - Street 2:#115
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080
Mailing Address - Country:US
Mailing Address - Phone:770-431-2354
Mailing Address - Fax:770-436-7143
Practice Address - Street 1:400 TECHNOLOGY CT SE STE J
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-5237
Practice Address - Country:US
Practice Address - Phone:770-866-5700
Practice Address - Fax:770-436-7143
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031313101YA0400X
GA31313207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000471479FMedicaid
GA000471479FMedicaid
B03010Medicare UPIN