Provider Demographics
NPI:1144227653
Name:RICHMOND, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:RICHMOND
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 1:560 W MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2278
Mailing Address - Country:US
Mailing Address - Phone:231-487-2460
Mailing Address - Fax:231-487-6596
Practice Address - Street 1:560 W MITCHELL ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2278
Practice Address - Country:US
Practice Address - Phone:231-487-2460
Practice Address - Fax:231-487-6596
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058393207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104085730Medicaid
0M74020008Medicare ID - Type Unspecified
MI104085730Medicaid