Healthcare Provider Details

I. General information

NPI: 1386753564
Provider Name (Legal Business Name): SAM W RICHWINE JR. M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1296 SIMS ST SUITE B
GAINESVILLE GA
30501-3850
US

IV. Provider business mailing address

1296 SIMS ST SUITE B
GAINESVILLE GA
30501-3850
US

V. Phone/Fax

Practice location:
  • Phone: 770-534-1856
  • Fax: 770-531-0355
Mailing address:
  • Phone: 770-534-1856
  • Fax: 770-531-0355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number019761
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: