Provider Demographics
NPI:1700945045
Name:RICHARDSON, GARY S (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:S
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:PO BOX 4119
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-4119
Mailing Address - Country:US
Mailing Address - Phone:734-926-9264
Mailing Address - Fax:734-527-6199
Practice Address - Street 1:1418 IROQUOIS PL
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4638
Practice Address - Country:US
Practice Address - Phone:734-730-6753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI073466207R00000X, 207RE0101X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
GR073466OtherCOMMERCIAL-COMMERCIAL NUMBER
700H262220OtherBLUE CROSS-BLUE CROSS
GR073466OtherCHAMPUS-CHAMPUS
MI411790510Medicaid
D33553Medicare UPIN
D33553Medicare UPIN