Provider Demographics
NPI:1881685444
Name:RICHARDSON, TY E (MD)
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:E
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 1:4130 DUTCHMANS LN
Mailing Address - Street 2:STE 300
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4713
Mailing Address - Country:US
Mailing Address - Phone:502-897-1794
Mailing Address - Fax:502-897-0093
Practice Address - Street 1:4130 DUTCHMANS LN
Practice Address - Street 2:STE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4713
Practice Address - Country:US
Practice Address - Phone:502-897-1794
Practice Address - Fax:502-897-0093
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31339207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64015753Medicaid
9481389002OtherCIGNA INS
7807142OtherAETNA INS
000000179986OtherANTHEM INS
7807142OtherAETNA INS
KY1277609Medicare PIN
000000179986OtherANTHEM INS