Provider Demographics
NPI:1477545937
Name:RICHARDS, KEN R
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:R
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:KEN
Other - Middle Name:R
Other - Last Name:RICHARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2320 E 93RD STREET
Mailing Address - Street 2:1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-5256
Mailing Address - Country:US
Mailing Address - Phone:773-967-4130
Mailing Address - Fax:773-967-4138
Practice Address - Street 1:2320 E 93RD ST
Practice Address - Street 2:TRINITY HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3983
Practice Address - Country:US
Practice Address - Phone:773-324-0553
Practice Address - Fax:773-324-0553
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233117174400000X
IL036-114696208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007312881Medicaid
VA007312881Medicaid
VA020001593Medicare ID - Type Unspecified