Provider Demographics
NPI:1770578635
Name:RICHERT, DANIEL RAYMOND (AUD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:RAYMOND
Last Name:RICHERT
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 S 25TH ST
Mailing Address - Street 2:P.O. BOX 503
Mailing Address - City:BETHANY
Mailing Address - State:MO
Mailing Address - Zip Code:64424-2611
Mailing Address - Country:US
Mailing Address - Phone:660-425-7400
Mailing Address - Fax:660-425-7404
Practice Address - Street 1:1101 S 25TH ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:MO
Practice Address - Zip Code:64424-2611
Practice Address - Country:US
Practice Address - Phone:660-425-7400
Practice Address - Fax:660-425-7404
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01305231H00000X
IA341231H00000X
IA596237700000X
MO754237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO10001399000OtherCOMMUNITY HEALTH PLAN
IA0979252Medicaid
MO17193010OtherBLUE CROSS BLUE SHIELD
MO17194018OtherBLUC CROSS BLUE SHIELD
MO45-00098OtherUNITED HEALTHCARE
MO8192OtherHEALTHCARE USA
MOA990274Medicare ID - Type Unspecified