Healthcare Provider Details

I. General information

NPI: 1215785993
Provider Name (Legal Business Name): CHADRICK LAMAR RICHARDSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 ALEXANDER LN
BETHLEHEM GA
30620-1838
US

IV. Provider business mailing address

720 WESTVIEW DR SW
ATLANTA GA
30310-1458
US

V. Phone/Fax

Practice location:
  • Phone: 229-854-9056
  • Fax:
Mailing address:
  • Phone: 404-756-1959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number14124
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: