Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 24642 | SC |
Y | 207Q00000X | Family Doctor | 052047 | GA |
N | 207QA0505X | Family Doctor - Adult Medicine | 052047 | GA |
NPI | 1235107772 |
---|---|
Provider Name | Eddie Richardson |
First Address | Eatonton, GA 31024-9546 |
Second Address | Eatonton, GA 31024-9546 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/03/2006 |
Last Update Date | 10/02/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T85360 | (05) | SC |