Healthcare Provider Details

I. General information

NPI: 1962645770
Provider Name (Legal Business Name): BRECK T RICHARDSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 HWY 12 WEST
KOSCIUSKO MS
39090
US

IV. Provider business mailing address

PO BOX 23996
JACKSON MS
39225
US

V. Phone/Fax

Practice location:
  • Phone: 662-289-1800
  • Fax: 662-289-2486
Mailing address:
  • Phone: 601-206-6100
  • Fax: 601-206-6052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21932
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: