Provider Demographics
NPI:1699703058
Name:BARDIN, RICHARD L (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:BARDIN
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 1:2002 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-4074
Mailing Address - Country:US
Mailing Address - Phone:269-687-0200
Mailing Address - Fax:269-684-0199
Practice Address - Street 1:2002 S 11TH ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-4074
Practice Address - Country:US
Practice Address - Phone:269-687-0200
Practice Address - Fax:269-684-0199
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085001207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI04-30549OtherPHP
P00233286OtherRAILROAD MEDICARE
2829484OtherCIGNA
MI1101110651OtherBLUE CROSS
MI4718487Medicaid
MI4718487Medicaid
MI04-30549OtherPHP
MI1101110651OtherBLUE CROSS