Provider Demographics
NPI:1629244819
Name:RICHARD W. RADEMACHER, JR
Entity Type:Organization
Organization Name:RICHARD W. RADEMACHER, JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:OLEXA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-983-7261
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002496152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI943155278Medicaid
MI943155278Medicaid
MI1171940001Medicare NSC
MIOM11660Medicare PIN