Healthcare Provider Details

I. General information

NPI: 1962428557
Provider Name (Legal Business Name): RICHARD SO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 01/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20800 WESTGATE MALL SUITE 400
FAIRVIEW PARK OH
44126-1323
US

IV. Provider business mailing address

20800 WESTGATE MALL SUITE 400
FAIRVIEW PARK OH
44126-1323
US

V. Phone/Fax

Practice location:
  • Phone: 440-356-2272
  • Fax: 440-356-2299
Mailing address:
  • Phone: 440-356-2272
  • Fax: 440-356-2299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35090551
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number35090551
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: