Provider Demographics
NPI:1861480964
Name:RICHARDSON, ERIC T (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:T
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:PO BOX 18667
Mailing Address - Street 2:
Mailing Address - City:ERLANGER
Mailing Address - State:KY
Mailing Address - Zip Code:41018-0667
Mailing Address - Country:US
Mailing Address - Phone:859-572-3617
Mailing Address - Fax:859-572-2326
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-572-3617
Practice Address - Fax:859-572-2326
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28930207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000618978JMedicaid
IN200916620Medicaid
OH2793320Medicaid
KY7100032130Medicaid
GA000618978JMedicaid
KY0969423Medicare PIN
F73286Medicare UPIN
GA93BBGBVMedicare PIN
KYK002901Medicare PIN
KYK173610Medicare PIN
OH2793320Medicaid
P00612935Medicare PIN
GAP00029711Medicare PIN