MEDICARE: DR. RICHARD J MELLITT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	2000168805	MO

General Provider Information

NPI Number	:	1730171026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD J MELLITT M.D.

Provider Business Mailing Address
First Line	:	1605 E BROADWAY STE 210
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65201-8023
Country	:	US
Telephone Number	:	573-815-4130
Fax Number	:	573-815-4135

Provider Business Practice Location Address
First Line	:	1605 E BROADWAY STE 210
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65201-8023
Country	:	US
Telephone Number	:	573-815-4130
Fax Number	:	573-815-4135

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	09/22/2021

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