Provider Demographics
NPI:1780627356
Name:RICHARDSON, HARRY LEE JR (MD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:LEE
Last Name:RICHARDSON
Suffix:JR
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 670
Mailing Address - Street 2:
Mailing Address - City:REFORM
Mailing Address - State:AL
Mailing Address - Zip Code:35481-0670
Mailing Address - Country:US
Mailing Address - Phone:205-375-6251
Mailing Address - Fax:205-375-8199
Practice Address - Street 1:514 10TH AVE SW
Practice Address - Street 2:
Practice Address - City:REFORM
Practice Address - State:AL
Practice Address - Zip Code:35481
Practice Address - Country:US
Practice Address - Phone:205-375-6251
Practice Address - Fax:205-375-8199
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10330207P00000X
AL11725207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS562251777OtherBLUE CROSS
MS7306387RICOtherALABAMA BLUE CROSS
MSP00204381OtherRAILROAD MEDICARE
MS00120095Medicaid
MS009972520OtherALABAMA MEDICAID
MS00120095Medicaid
AL000076801Medicare PIN