Provider Demographics
NPI:1417932252
Name:RICHARDSON, GEORGE R (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:R
Last Name:RICHARDSON
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 1:217 DOZIER BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4090
Mailing Address - Country:US
Mailing Address - Phone:843-669-5162
Mailing Address - Fax:843-667-4573
Practice Address - Street 1:1106 CHUCK DAWLEY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-4183
Practice Address - Country:US
Practice Address - Phone:843-849-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17564208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC175642Medicaid
SC320058385OtherSTANDARD TAX ID
SC175642Medicaid
SCG52073Medicare UPIN
SCP00126083Medicare ID - Type UnspecifiedRAILROAD MEDICARE