Healthcare Provider Details

I. General information

NPI: 1114244472
Provider Name (Legal Business Name): RICHARDS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 S 3RD ST
LOUISVILLE KY
40203-2902
US

IV. Provider business mailing address

1126 S 3RD ST
LOUISVILLE KY
40203-2902
US

V. Phone/Fax

Practice location:
  • Phone: 502-749-9550
  • Fax: 502-749-9551
Mailing address:
  • Phone: 502-749-9550
  • Fax: 502-749-9551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number13689
License Number StateKY

VIII. Authorized Official

Name: GLEN RICHARDS
Title or Position: OWNER
Credential: MD
Phone: 502-749-9550