Provider Demographics
NPI:1205834074
Name:RICHARDSON, TYRUN KEITH (MD)
Entity Type:Individual
Prefix:
First Name:TYRUN
Middle Name:KEITH
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:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1965 S FREMONT AVE
Practice Address - Street 2:STE 370
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2201
Practice Address - Country:US
Practice Address - Phone:417-820-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-33531208800000X
OK31026208800000X
MO2016012292208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
ARPENDINGMedicaid
OK200456750HMedicaid
OK200566690AMedicaid
KS200615150AMedicaid
G93000005Medicare PIN
OKOKA105715Medicare PIN
OK383334YK1NMedicare PIN
MOPENDINGMedicaid
A10622Medicare UPIN
ARPENDINGMedicaid