Provider Demographics
NPI:1710293881
Name:RICHARDSON, GARY MEADE (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:MEADE
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 1:300 N COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36037-2025
Mailing Address - Country:US
Mailing Address - Phone:334-382-2681
Mailing Address - Fax:334-383-9541
Practice Address - Street 1:300 N COLLEGE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:AL
Practice Address - Zip Code:36037-2025
Practice Address - Country:US
Practice Address - Phone:334-382-2681
Practice Address - Fax:334-383-9541
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111635208D00000X
ALMD.30478208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-17014OtherBC/BS
AL128794Medicaid
1871003533OtherGROUP NPI
AL102I017874Medicare PIN
AL128794Medicaid