Provider Demographics
NPI:1225049232
Name:MEDLEY, RICHARD W JR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:MEDLEY
Suffix:JR
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 1:1220 FREDERICA ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-3057
Mailing Address - Country:US
Mailing Address - Phone:270-683-8858
Mailing Address - Fax:
Practice Address - Street 1:1220 FREDERICA ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-3057
Practice Address - Country:US
Practice Address - Phone:270-683-8858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-03-07
Deactivation Date:2013-05-14
Deactivation Code:
Reactivation Date:2013-06-05
Provider Licenses
StateLicense IDTaxonomies
KY13758207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000068534OtherANTHEM
KY64137581Medicaid
KY64137581Medicaid
KY000000068534OtherANTHEM
KY1080801Medicare ID - Type Unspecified