1568530541 NPI number — GEORGIA S RICHARDSON RD,CDE

Table of content: GEORGIA S RICHARDSON RD,CDE (NPI 1568530541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568530541 NPI number — GEORGIA S RICHARDSON RD,CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICHARDSON
Provider First Name:
GEORGIA
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD,CDE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NUGENT
Provider Other First Name:
GEORGIA
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD,CDE
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1568530541
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 WATER ST FL 12
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10041-0004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-680-2888
Provider Business Mailing Address Fax Number:
516-542-5556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2832 LINDEN BOULEVARD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-240-2000
Provider Business Practice Location Address Fax Number:
718-240-2215
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133N00000X , with the licence number:  001981 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001981 . This is a "LICENSE NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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