Provider Demographics
NPI:1609948124
Name:ALLEN, RICHARD M (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:ALLEN
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 1:890 GARFIELD AVE
Mailing Address - Street 2:200
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-4723
Mailing Address - Country:US
Mailing Address - Phone:847-549-1818
Mailing Address - Fax:847-680-1573
Practice Address - Street 1:890 GARFIELD AVE
Practice Address - Street 2:200
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-4723
Practice Address - Country:US
Practice Address - Phone:847-549-1818
Practice Address - Fax:847-680-1573
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067062174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD16094Medicare UPIN