Provider Demographics
NPI:1679998017
Name:COLEMAN, RICHARD GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GLENN
Last Name:COLEMAN
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 1:7103 116TH AVE
Mailing Address - Street 2:
Mailing Address - City:FENNVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49408-9730
Mailing Address - Country:US
Mailing Address - Phone:269-227-3459
Mailing Address - Fax:
Practice Address - Street 1:7103 116TH AVE
Practice Address - Street 2:
Practice Address - City:FENNVILLE
Practice Address - State:MI
Practice Address - Zip Code:49408-9730
Practice Address - Country:US
Practice Address - Phone:269-227-3459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032173208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice