Provider Demographics
NPI:1568520252
Name:RICHARDSON, STEPHEN RANDOLPH (DO)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:RANDOLPH
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 N ROCHESTER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48306-4362
Mailing Address - Country:US
Mailing Address - Phone:248-650-1520
Mailing Address - Fax:
Practice Address - Street 1:6700 N ROCHESTER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48306-4362
Practice Address - Country:US
Practice Address - Phone:248-650-1520
Practice Address - Fax:248-650-1530
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010854207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2976099 TYPE 11Medicaid
MI0856304754 001OtherBCBS
MI2976099 TYPE 11Medicaid