Healthcare Provider Details

I. General information

NPI: 1548278971
Provider Name (Legal Business Name): KELLY RICHARDSON MD05/
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 10/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 56TH ST SW
WYOMING MI
49509-9704
US

IV. Provider business mailing address

1200 56TH ST SW
WYOMING MI
49509-9704
US

V. Phone/Fax

Practice location:
  • Phone: 616-243-5707
  • Fax: 616-243-1170
Mailing address:
  • Phone: 616-243-5707
  • Fax: 616-243-1170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301079769
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number4301079769
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: