MEDICARE: FRED RICHARDSON JR. M.D.

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	207Q00000X	Family Medicine Physician	036078174	IL

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

General Provider Information

NPI Number	:	1194702092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FRED RICHARDSON JR. M.D.

Provider Business Mailing Address
First Line	:	904 MEDICAL PARK DR
Second Line	:	SUITE 3
City	:	EFFINGHAM
State	:	IL
Zip	:	62401-2193
Country	:	US
Telephone Number	:	217-540-2350
Fax Number	:	217-347-2323

Provider Business Practice Location Address
First Line	:	904 MEDICAL PARK DR
Second Line	:	SUITE 3
City	:	EFFINGHAM
State	:	IL
Zip	:	62401-2193
Country	:	US
Telephone Number	:	217-540-2350
Fax Number	:	217-347-2323

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2005
Last Update Date	:	04/01/2021

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