=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154306116
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES MICHAEL RICHARDSON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 WADE AVE
-----------------------------------------------------
City | CATONSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21228-4663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-402-6871
-----------------------------------------------------
Fax | 410-402-6880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7662 SWEET HOURS WAY
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21046-2476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-381-2752
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | D0038459
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------