Provider Demographics
NPI:1578538070
Name:CHILDRESS, RICHARD DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DALE
Last Name:CHILDRESS
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:PO BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5659 S REX RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3821
Practice Address - Country:US
Practice Address - Phone:901-763-3636
Practice Address - Fax:901-763-3694
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39115207RE0101X
MS19582207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00447294OtherMEDICARE RAILROAD
TNI24527Medicare UPIN
MS512I460003Medicare PIN
TN3326923Medicare PIN