Provider Demographics
NPI:1912971094
Name:RICHARDSON, MICHAEL T (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 MAC LANE
Mailing Address - Street 2:AVERA MEDICAL GROUP PIERRE
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-945-5255
Mailing Address - Fax:605-945-5295
Practice Address - Street 1:100 MAC LANE
Practice Address - Street 2:AVERA MEDICAL GROUP PIERRE
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501
Practice Address - Country:US
Practice Address - Phone:605-945-5255
Practice Address - Fax:605-945-5295
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD3850207Q00000X
SDSD3850207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5600170Medicaid
SD5600173Medicaid
SD3514Medicare ID - Type Unspecified
SD5600173Medicaid
SD103112Medicare PIN