Provider Demographics
NPI:1932281821
Name:RICHARDSON, JAMES K (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:K
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 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:325 E EISENHOWER PKWY
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-3364
Practice Address - Country:US
Practice Address - Phone:734-936-7175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051649204R00000X, 207R00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2682830Medicaid
MI0H16021025Medicare ID - Type Unspecified
MI2682830Medicaid