Healthcare Provider Details

I. General information

NPI: 1912971094
Provider Name (Legal Business Name): MICHAEL T RICHARDSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAC LANE AVERA MEDICAL GROUP PIERRE
PIERRE SD
57501
US

IV. Provider business mailing address

100 MAC LANE AVERA MEDICAL GROUP PIERRE
PIERRE SD
57501
US

V. Phone/Fax

Practice location:
  • Phone: 605-945-5255
  • Fax: 605-945-5295
Mailing address:
  • Phone: 605-945-5255
  • Fax: 605-945-5295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3850
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberSD3850
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: