Provider Demographics
NPI:1861481350
Name:KING, RICHARD M (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:KING
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 1:26908 DETROIT RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2398
Mailing Address - Country:US
Mailing Address - Phone:440-617-1823
Mailing Address - Fax:440-617-0884
Practice Address - Street 1:3985 WARRENSVILLE CENTER RD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-6764
Practice Address - Country:US
Practice Address - Phone:216-283-4494
Practice Address - Fax:216-283-2351
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043622207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0402586Medicaid
OHP00067727OtherRR MEDICARE
OHP00067727OtherRR MEDICARE
OH0465034Medicare PIN