Provider Demographics
NPI:1548278971
Name:RICHARDSON, KELLY (MD05/)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MD05/
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 56TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9704
Mailing Address - Country:US
Mailing Address - Phone:616-243-5707
Mailing Address - Fax:616-243-1170
Practice Address - Street 1:1200 56TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-9704
Practice Address - Country:US
Practice Address - Phone:616-243-5707
Practice Address - Fax:616-243-1170
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079769207R00000X, 207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI381360529OtherTAX ID
P25800003Medicare PIN
I64617Medicare UPIN