Provider Demographics
NPI:1184652406
Name:RICHARDSON, SCOTT KENCHILOE (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:KENCHILOE
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 1:4555 OTTAWA PLACE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303
Mailing Address - Country:US
Mailing Address - Phone:303-494-5588
Mailing Address - Fax:
Practice Address - Street 1:605 PARFET ST
Practice Address - Street 2:# 103
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-5576
Practice Address - Country:US
Practice Address - Phone:303-758-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27137207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01271378Medicaid
CO26701316Medicaid
COC806182Medicare PIN
COE34146Medicare UPIN
CO01271378Medicaid