Provider Demographics
NPI:1851357206
Name:BLOCK, RICHARD ALLAN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLAN
Last Name:BLOCK
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 1:1160 N GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1104
Mailing Address - Country:US
Mailing Address - Phone:847-234-5296
Mailing Address - Fax:
Practice Address - Street 1:1160 N GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1104
Practice Address - Country:US
Practice Address - Phone:847-234-5296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022770Medicaid
132397Medicare ID - Type Unspecified
D14067Medicare UPIN