Provider Demographics
NPI:1659302289
Name:MCCOLLUM, RICHARD G JR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:MCCOLLUM
Suffix:JR
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 8500-6335
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0001
Mailing Address - Country:US
Mailing Address - Phone:215-807-8166
Mailing Address - Fax:215-807-8235
Practice Address - Street 1:3998 RED LION RD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1436
Practice Address - Country:US
Practice Address - Phone:215-612-4000
Practice Address - Fax:215-807-8235
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427812207P00000X
MO2019031790207P00000X
IL036150432207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101701845-01OtherAMERICHOICE -FT
PA1017018450002Medicaid
PA1017018450003Medicaid
PA1882159OtherHIGHMARK BLUE SHIELD
PA274408400OtherKEYSTONE, IBC
PA101701845-02OtherAMERICHOICE FF
PA101701845-03OtherAMERICHOICE - FB
PA07645OtherHEALTH PARTNERS
PA1882159OtherPERSONAL CHOICE
PA30034608OtherKEYSTONE MERCY
OR024508Medicaid
PA1017018450001Medicaid
PA1017018450002Medicaid
PA07645OtherHEALTH PARTNERS
PA274408400OtherKEYSTONE, IBC