Provider Demographics
NPI:1730238254
Name:RICHARDSON, ELLEN HARRIS (MD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:HARRIS
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 BRYAN WOODS ROAD
Mailing Address - Street 2:ELLEN RICHARDSON MD
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31410-1225
Mailing Address - Country:US
Mailing Address - Phone:912-898-1122
Mailing Address - Fax:912-898-9944
Practice Address - Street 1:102 BRYAN WOODS ROAD
Practice Address - Street 2:ELLEN RICHARDSON MD
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31410-1225
Practice Address - Country:US
Practice Address - Phone:912-898-1122
Practice Address - Fax:912-898-9944
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA40528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAB77412Medicare UPIN
GA08BBSDLMedicare PIN