Provider Demographics
NPI:1669437125
Name:RICHARDSON, SCOTT C (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
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 1:170 AMENDMENT AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732
Mailing Address - Country:US
Mailing Address - Phone:803-324-7607
Mailing Address - Fax:803-324-1449
Practice Address - Street 1:170 AMENDMENT AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732
Practice Address - Country:US
Practice Address - Phone:803-324-7607
Practice Address - Fax:803-324-1449
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23173207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC200160Medicaid
G85680Medicare UPIN
SC2467Medicare ID - Type Unspecified