Provider Demographics
NPI:1194702092
Name:RICHARDSON, FRED JR (MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:RICHARDSON
Suffix:JR
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 1:904 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2193
Mailing Address - Country:US
Mailing Address - Phone:217-540-2350
Mailing Address - Fax:217-347-2323
Practice Address - Street 1:904 MEDICAL PARK DR
Practice Address - Street 2:SUITE 3
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2193
Practice Address - Country:US
Practice Address - Phone:217-540-2350
Practice Address - Fax:217-347-2323
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078174207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078174Medicaid
ILE35530Medicare UPIN
IL036078174Medicaid
IL211645Medicare PIN