Individual
KELLY RICHARDSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD05/
Contact information
Practice address
1200 56TH ST SW, WYOMING, MI 49509-9704
(616) 243-5707
(616) 243-1170
Mailing address
1200 56TH ST SW, WYOMING, MI 49509-9704
(616) 243-5707
(616) 243-1170
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
4301079769
MI
207RA0000X
Adolescent Medicine (Internal Medicine) Physician
Primary
4301079769
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
381360529
TAX ID
MI
Enumeration date
08/03/2006
Last updated
10/18/2011
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