Provider Demographics
NPI:1578513180
Name:RADEMACHER, RICHARD W (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:RADEMACHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2457
Mailing Address - Country:US
Mailing Address - Phone:269-983-7261
Mailing Address - Fax:269-983-0997
Practice Address - Street 1:717 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2457
Practice Address - Country:US
Practice Address - Phone:269-983-7261
Practice Address - Fax:269-983-0997
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002496152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI943155278Medicaid
MI943155278Medicaid
MI1171940001Medicare NSC
MIU27329Medicare UPIN