Provider Demographics
NPI:1316055130
Name:RICHLAND RADIOLOGY LTD
Entity type:Organization
Organization Name:RICHLAND RADIOLOGY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:V
Authorized Official - Last Name:BOUFFARD
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:618-262-7303
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:MT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863
Mailing Address - Country:US
Mailing Address - Phone:618-262-7303
Mailing Address - Fax:618-262-2304
Practice Address - Street 1:326 W 3RD STREET
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863
Practice Address - Country:US
Practice Address - Phone:618-262-7303
Practice Address - Fax:618-262-2304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054461Medicaid
986210Medicare ID - Type Unspecified