Provider Demographics
NPI:1639107261
Name:RICHARDSON, MARK E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:RICHARDSON
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 1:1169 EASTERN PKWY
Mailing Address - Street 2:SUITE G 71
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1417
Mailing Address - Country:US
Mailing Address - Phone:502-456-6217
Mailing Address - Fax:502-456-4440
Practice Address - Street 1:4000 KRESGE WAY
Practice Address - Street 2:PATHOLOGY DEPT
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4605
Practice Address - Country:US
Practice Address - Phone:502-897-8226
Practice Address - Fax:502-897-8215
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21630207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000062182OtherANTHEM BL CROSS BL SHIELD
220020761OtherRAILROAD MEDICARE
KY1100181OtherUNITED HEALTHCARE
OH31155000400OtherWORKERS COMP OHIO
KY6598690OtherCIGNA HEALTHCARE
IN100373830AOtherMEDICAID INDIANA
KY2432721000OtherPASSPORT ADVANTAGE
KY104509OtherHEALTH PARTNERS
KY1049932OtherMEDICAID PASSPORT
KY64216302Medicaid
FL124519600OtherWORKERS COMP FLORIDA
KY104509OtherHEALTH PARTNERS
KY1049932OtherMEDICAID PASSPORT