Provider Demographics
NPI:1265464341
Name:RICHARDSON, MAUREEN E (MD)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:E
Last Name:RICHARDSON
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 1:777 CLINTON AVE S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-1401
Mailing Address - Country:US
Mailing Address - Phone:585-279-4620
Mailing Address - Fax:585-279-4625
Practice Address - Street 1:777 CLINTON AVE S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-1401
Practice Address - Country:US
Practice Address - Phone:585-279-4620
Practice Address - Fax:585-279-4625
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY380218363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS52818Medicare UPIN
NYCC3097Medicare PIN