Provider Demographics
NPI:1922040195
Name:RICHERT, ALLEN CARL (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:CARL
Last Name:RICHERT
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5815
Mailing Address - Fax:601-984-5842
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPARTMENT OF PSYCHIATRY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5815
Practice Address - Fax:601-984-5842
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS160112084P0800X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL156867Medicaid
MSP01227746OtherRR MEDICARE PTAN
MS00120748Medicaid
MS260043154OtherRAILROAD MEDICARE
MS512I260017Medicare PIN
MSG54248Medicare UPIN
MS00120748Medicaid
MSP00041377Medicare PIN
MS302I268813Medicare PIN