Provider Demographics
NPI:1992777296
Name:MACAULEY, RICHARD WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WAYNE
Last Name:MACAULEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 932879
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0025
Mailing Address - Country:US
Mailing Address - Phone:877-595-1090
Mailing Address - Fax:989-345-3163
Practice Address - Street 1:565 PROGRESS ST
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-8601
Practice Address - Country:US
Practice Address - Phone:877-595-1090
Practice Address - Fax:989-345-3163
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042308208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF51015OtherBLUE CROSS
MI930117513OtherRAILROAD MEDICARE
A78765Medicare UPIN