Provider Demographics
NPI:1861496762
Name:RICHARDSON, KEVIN A (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
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 1:502 ELM ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2512
Mailing Address - Country:US
Mailing Address - Phone:505-841-1000
Mailing Address - Fax:505-843-2956
Practice Address - Street 1:502 ELM ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2512
Practice Address - Country:US
Practice Address - Phone:505-841-1000
Practice Address - Fax:505-843-2592
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-290208G00000X
IL036125892208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ1459Medicaid
IL01618941OtherBLUECROSS BLUESHIELD
IL036125892Medicaid
NMJ1459Medicaid
IL211578004Medicare PIN
IL53555010Medicare PIN
IL969780009Medicare PIN