Provider Demographics
NPI:1265499776
Name:RICHARD, GARY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MICHAEL
Last Name:RICHARD
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 204097
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907
Mailing Address - Country:US
Mailing Address - Phone:706-855-9860
Mailing Address - Fax:706-860-7124
Practice Address - Street 1:3651 WHEELER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6521
Practice Address - Country:US
Practice Address - Phone:706-855-9860
Practice Address - Fax:706-860-7124
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029293207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG29293Medicaid
GA000505414CMedicaid
GA10065573OtherAMERIGROUP
GAP00267043OtherRAILROAD MEDICARE
GAP00267043OtherRAILROAD MEDICARE