Provider Demographics
NPI:1083689376
Name:RICHARDS, KENNETH MAX (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MAX
Last Name:RICHARDS
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 1:1905 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-5209
Mailing Address - Country:US
Mailing Address - Phone:970-352-0405
Mailing Address - Fax:
Practice Address - Street 1:1800 15TH ST
Practice Address - Street 2:SUITE 340
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-4500
Practice Address - Country:US
Practice Address - Phone:970-378-4593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31556208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68738030Medicaid
COC533538Medicare PIN
COH54260Medicare UPIN