Provider Demographics
NPI:1467439968
Name:RICHBOURG, HENRY R (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:R
Last Name:RICHBOURG
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 1:907 18TH ST E
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3643
Mailing Address - Country:US
Mailing Address - Phone:229-353-3422
Mailing Address - Fax:
Practice Address - Street 1:416A E MCPHERSON AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:GA
Practice Address - Zip Code:31639-2275
Practice Address - Country:US
Practice Address - Phone:229-686-2093
Practice Address - Fax:229-686-7150
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0001387AMedicaid
GA0001387AMedicaid
08BDGTDMedicare ID - Type Unspecified