Provider Demographics
NPI:1962465476
Name:LICHTENBERG, RICHARD (MS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:LICHTENBERG
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7339
Mailing Address - Fax:
Practice Address - Street 1:1 INGALLS DR
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-3558
Practice Address - Country:US
Practice Address - Phone:708-331-7800
Practice Address - Fax:708-339-0695
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360823912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082391Medicaid
ILF86145Medicare UPIN
ILL88196Medicare ID - Type Unspecified