Provider Demographics
NPI:1811969975
Name:RICHARDS, MICHAEL D (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-695-6697
Mailing Address - Fax:
Practice Address - Street 1:101 BUSINESS PARK BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8401
Practice Address - Country:US
Practice Address - Phone:803-296-7846
Practice Address - Fax:803-296-9699
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA543363A00000X
SC543363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0093PAMedicaid
SCS826798946OtherMEDICARE PTAN
SCQM0677Medicaid
SCS826797275Medicare ID - Type Unspecified
SCQM0677Medicaid