Provider Demographics
NPI:1518038314
Name:RICHARDSON, RANDAL S (PT)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:S
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4230 E. NATIONAL ROAD (REAR)
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-1714
Mailing Address - Country:US
Mailing Address - Phone:937-323-8000
Mailing Address - Fax:937-323-6960
Practice Address - Street 1:4230 E. NATIONAL ROAD (REAR)
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-1714
Practice Address - Country:US
Practice Address - Phone:937-323-8000
Practice Address - Fax:937-323-6960
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT006483208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2587606Medicaid
OH4157751Medicare PIN