Provider Demographics
NPI:1033105093
Name:RICHARDSON, ROBERT R (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:R
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 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-933-4056
Mailing Address - Fax:630-933-4057
Practice Address - Street 1:351 DELNOR
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134
Practice Address - Country:US
Practice Address - Phone:630-933-4056
Practice Address - Fax:630-933-4057
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-044156207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036044156Medicaid
IL036044156Medicaid
ILIL4379002Medicare PIN
ILIL4378002Medicare PIN
ILL85326/357801Medicare ID - Type Unspecified
ILIL4377002Medicare PIN