Provider Demographics
NPI:1467466466
Name:GARY J RICHMOND,MD,PA
Entity Type:Organization
Organization Name:GARY J RICHMOND,MD,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:RICHMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-524-2250
Mailing Address - Street 1:315 SE 14TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1929
Mailing Address - Country:US
Mailing Address - Phone:954-524-2250
Mailing Address - Fax:954-524-5833
Practice Address - Street 1:315 SE 14TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1929
Practice Address - Country:US
Practice Address - Phone:954-524-2250
Practice Address - Fax:954-524-5833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000894200Medicaid
FL000894200Medicaid