Healthcare Provider Details

I. General information

NPI: 1841349917
Provider Name (Legal Business Name): GAINES E RICHARDSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 2ND ST
NEW GLARUS WI
53574-9326
US

IV. Provider business mailing address

1800 2ND ST
NEW GLARUS WI
53574-9326
US

V. Phone/Fax

Practice location:
  • Phone: 608-527-5296
  • Fax:
Mailing address:
  • Phone: 608-527-5296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38784
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-102494
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number38784-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: