Provider Demographics
NPI: | 1033159132 |
---|---|
Name: | RICHTER, KENNETH J (DO) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | KENNETH |
Middle Name: | J |
Last Name: | RICHTER |
Suffix: | |
Gender: | M |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 34505 WEST 12 MILE RD SUITE 100 |
Mailing Address - Street 2: | |
Mailing Address - City: | FARMINGTON HILLS |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48331 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 734-343-7500 |
Mailing Address - Fax: | 312-957-9991 |
Practice Address - Street 1: | 34505 WEST 12 MILE RD SUITE 100 |
Practice Address - Street 2: | |
Practice Address - City: | FARMINGTON HILLS |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48331 |
Practice Address - Country: | US |
Practice Address - Phone: | 734-343-7500 |
Practice Address - Fax: | 312-957-9991 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-07 |
Last Update Date: | 2019-07-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 5101007564 | 208100000X, 2081P0004X, 2081P0010X, 2081P2900X, 2081S0010X, 208VP0000X, 208VP0014X, 204C00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 204C00000X | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine | |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | |
No | 2081P0004X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Spinal Cord Injury Medicine |
No | 2081P0010X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pediatric Rehabilitation Medicine |
No | 2081P2900X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No | 2081S0010X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
No | 208VP0000X | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No | 208VP0014X | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 2905041 TYPE 11 | Medicaid | |
MI | P42800001 | Medicare PIN | |
MI | A79943 | Medicare UPIN | |
MI | 2905041 TYPE 11 | Medicaid |