Healthcare Provider Details

I. General information

NPI: 1225075708
Provider Name (Legal Business Name): NWANNEKA RICHARDSON M.B.B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 04/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 BURNHAM AVE
CALUMET CITY IL
60409-3401
US

IV. Provider business mailing address

510 BURNHAM AVE
CALUMET CITY IL
60409-3401
US

V. Phone/Fax

Practice location:
  • Phone: 708-862-0305
  • Fax:
Mailing address:
  • Phone: 708-862-0305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036-102719
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: