Provider Demographics
NPI:1760561740
Name:RICHARDSON, MARY S (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 EAGLE PARK DR NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7057
Mailing Address - Country:US
Mailing Address - Phone:616-285-9090
Mailing Address - Fax:616-285-7947
Practice Address - Street 1:3200 EAGLE PARK DR NE
Practice Address - Street 2:SUITE 102
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7057
Practice Address - Country:US
Practice Address - Phone:616-285-9090
Practice Address - Fax:616-285-7947
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMR050676207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB46227Medicare UPIN
MI0N65680Medicare ID - Type Unspecified