Provider Demographics
NPI:1376651943
Name:SHROUDS, RICHARD D (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:SHROUDS
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 1:300 RICE MEADOW WAY STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-8424
Mailing Address - Country:US
Mailing Address - Phone:803-788-6360
Mailing Address - Fax:803-462-0312
Practice Address - Street 1:601 CLEMSON RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-4341
Practice Address - Country:US
Practice Address - Phone:803-788-6146
Practice Address - Fax:803-462-0312
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23441208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC234411Medicaid
SC234411Medicaid