MEDICARE: DR. EUGENE A. RICHARDSON III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	0401005258	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	003363	OTHER	VA	ANTHEM
3	691160	OTHER	PA	UNITED CONCORDIA
4	4066921	OTHER	TN	BC/BS

General Provider Information

NPI Number	:	1184894404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. EUGENE A. RICHARDSON III

Provider Business Mailing Address
First Line	:	23 SHORE ST
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23803-5818
Country	:	US
Telephone Number	:	804-861-5331
Fax Number	:	804-861-5351

Provider Business Practice Location Address
First Line	:	23 SHORE ST
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23803-5818
Country	:	US
Telephone Number	:	804-861-5331
Fax Number	:	804-861-5351

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. EUGENE ARTHUR RICHARDSON III
Credential	:
Telephone Number	:	804-861-5330

Provider Enumeration Date	:	03/03/2008
Last Update Date	:	03/03/2008

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