Provider Demographics
NPI:1619123056
Name:RICHARDSON PSYCHIATRIC P.A.
Entity Type:Organization
Organization Name:RICHARDSON PSYCHIATRIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-982-8535
Mailing Address - Street 1:4500 I 55 N STE 234
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5932
Mailing Address - Country:US
Mailing Address - Phone:601-982-8531
Mailing Address - Fax:601-982-1115
Practice Address - Street 1:4500 I 55 N STE 234
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5932
Practice Address - Country:US
Practice Address - Phone:601-982-8531
Practice Address - Fax:601-982-1115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119784Medicaid
LA1409871Medicaid
MS587948354BOtherBLUE CROSS BLUE SHIELD
MS587948354BOtherBLUE CROSS BLUE SHIELD
LA1409871Medicaid