Healthcare Provider Details

I. General information

NPI: 1518038314
Provider Name (Legal Business Name): RANDAL S RICHARDSON P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4230 E. NATIONAL ROAD (REAR)
SPRINGFIELD OH
45505-1714
US

IV. Provider business mailing address

4230 E. NATIONAL ROAD (REAR)
SPRINGFIELD OH
45505-1714
US

V. Phone/Fax

Practice location:
  • Phone: 937-323-8000
  • Fax: 937-323-6960
Mailing address:
  • Phone: 937-323-8000
  • Fax: 937-323-6960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPT006483
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: