Provider Demographics
NPI:1841349917
Name:RICHARDSON, GAINES E (MD)
Entity type:Individual
Prefix:
First Name:GAINES
Middle Name:E
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 1:1800 2ND ST
Mailing Address - Street 2:
Mailing Address - City:NEW GLARUS
Mailing Address - State:WI
Mailing Address - Zip Code:53574-9326
Mailing Address - Country:US
Mailing Address - Phone:608-527-5296
Mailing Address - Fax:
Practice Address - Street 1:1800 2ND ST
Practice Address - Street 2:
Practice Address - City:NEW GLARUS
Practice Address - State:WI
Practice Address - Zip Code:53574-9326
Practice Address - Country:US
Practice Address - Phone:608-527-5296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38784207Q00000X
IL036-102494207Q00000X
WI38784-20207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1017410OtherPHYSICIANS PLUS
32399400OtherHIRSP
390808509OtherWPS
90002361OtherWEA INS
80138944OtherMEDICARE RAILROAD
390808509OtherCT GENERAL
390808509OtherCIGNA
39080850991OtherUNITY
690004890OtherMEDIARE RAILROAD
WI32399400Medicaid
54979OtherHEALTH ALLIANCE MEDICAL
11565OtherDEAN HEALTH PLAN