Provider Demographics
NPI:1295736049
Name:RICHARDSON, KENRICK S (MD)
Entity type:Individual
Prefix:DR
First Name:KENRICK
Middle Name:S
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:71 VISTA RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45065-8755
Mailing Address - Country:US
Mailing Address - Phone:513-843-7632
Mailing Address - Fax:513-843-7945
Practice Address - Street 1:2155 DANA AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45207-1340
Practice Address - Country:US
Practice Address - Phone:513-843-7716
Practice Address - Fax:513-718-3223
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35.075358208M00000X
OH35-07-5358-R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2265945Medicaid
OH2265945Medicaid
OH4208062Medicare PIN
OH4208064Medicare PIN
OH4208061Medicare PIN