Provider Demographics
NPI:1326031196
Name:RICHARDSON, AUDREY C (MD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:C
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 1:1800 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3112
Mailing Address - Country:US
Mailing Address - Phone:630-614-4960
Mailing Address - Fax:630-682-3727
Practice Address - Street 1:1800 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3112
Practice Address - Country:US
Practice Address - Phone:630-614-4960
Practice Address - Fax:630-682-3727
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125043627207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01245139OtherMEDICARE RAILROAD (INDIVIDUAL)
IL125043627Medicaid
ILCE8792OtherMEDICARE RAILROAD (GROUP)
IL036114931OtherMEDICAID
IL920540OtherMEDICARE (GROUP PTAN)
MI4301086494Medicaid
ILF400100134OtherMEDICARE (INDIVIDUAL PTAN)
367830Medicare PIN