Provider Demographics
NPI:1538303409
Name:BARDACK, RICHARD A (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:BARDACK
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 1:55 WHITCHER ST NE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1155
Mailing Address - Country:US
Mailing Address - Phone:770-424-6893
Mailing Address - Fax:770-528-9938
Practice Address - Street 1:55 WHITCHER ST NE
Practice Address - Street 2:SUITE 350
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1155
Practice Address - Country:US
Practice Address - Phone:770-424-6893
Practice Address - Fax:770-528-9938
Is Sole Proprietor?:No
Enumeration Date:2009-04-22
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012782207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000132657LMedicaid
GA000132657NMedicaid
GA000132657QMedicaid
GA000132657MMedicaid
GA000132657OMedicaid
GA000132657PMedicaid
GA000132657RMedicaid
GA000132657NMedicaid
GA000132657RMedicaid