Provider Demographics
NPI:1063596542
Name:WHELAN, RICHARD (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WHELAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95000-3980
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-3980
Mailing Address - Country:US
Mailing Address - Phone:212-523-8172
Mailing Address - Fax:
Practice Address - Street 1:425 W 59TH ST
Practice Address - Street 2:STE 7B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-8022
Practice Address - Country:US
Practice Address - Phone:212-523-8172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY162960-1208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01093645Medicaid
NY32E421Medicare ID - Type Unspecified
NY01093645Medicaid