Healthcare Provider Details

I. General information

NPI: 1326031196
Provider Name (Legal Business Name): AUDREY C RICHARDSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 N MAIN ST
WHEATON IL
60187-3112
US

IV. Provider business mailing address

1800 N MAIN ST
WHEATON IL
60187-3112
US

V. Phone/Fax

Practice location:
  • Phone: 630-614-4960
  • Fax: 630-682-3727
Mailing address:
  • Phone: 630-614-4960
  • Fax: 630-682-3727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125043627
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: