Provider Demographics
NPI:1346339298
Name:RICHARDSON, CAROLINE R (MD)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:R
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 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:111 BREWSTER ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4400
Practice Address - Country:US
Practice Address - Phone:401-729-2304
Practice Address - Fax:401-729-2902
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301071372207Q00000X
RIMD18672207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3493829Medicaid
MI0H17630068Medicare ID - Type Unspecified
MI3493829Medicaid