Provider Demographics
NPI:1215032826
Name:RICHMOND, MARY ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:RICHMOND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E HURON ST
Mailing Address - Street 2:#12-205
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3197
Mailing Address - Country:US
Mailing Address - Phone:312-944-0688
Mailing Address - Fax:312-944-2886
Practice Address - Street 1:201 E HURON ST
Practice Address - Street 2:#12-205
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3197
Practice Address - Country:US
Practice Address - Phone:312-944-0688
Practice Address - Fax:312-944-2886
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076130207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4115066OtherAETNA
IL0360761301Medicaid
1175936OtherUNITED HEALTHCARE
4115066OtherAETNA
1175936OtherUNITED HEALTHCARE