Healthcare Provider Details

I. General information

NPI: 1508866351
Provider Name (Legal Business Name): MELVIN J. RICHARDS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 VALLEY VIEW DR. SUITE 202
MOLINE IL
61265-6180
US

IV. Provider business mailing address

615 VALLEY VIEW DR. SUITE 202
MOLINE IL
61265-6180
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-1072
  • Fax: 309-762-1094
Mailing address:
  • Phone: 309-762-1072
  • Fax: 309-762-1094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-045892
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number17497
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: