Healthcare Provider Details

I. General information

NPI: 1184674707
Provider Name (Legal Business Name): BERTHA PARTHENIA RICHARDSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 05/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 LILLINGTON AVE SUITE 202
CHARLOTTE NC
28204-3188
US

IV. Provider business mailing address

320 LILLINGTON AVE SUITE 202
CHARLOTTE NC
28204-3188
US

V. Phone/Fax

Practice location:
  • Phone: 704-372-0638
  • Fax: 704-372-0632
Mailing address:
  • Phone: 704-372-0638
  • Fax: 704-372-0632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number21856
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: