Provider Demographics
NPI:1801133053
Name:RADOSTITS, RICHARD (HIS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:RADOSTITS
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2333
Mailing Address - Country:US
Mailing Address - Phone:815-964-3131
Mailing Address - Fax:
Practice Address - Street 1:1415 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2333
Practice Address - Country:US
Practice Address - Phone:815-964-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3064237700000X
WI1373237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist