Basic Information
| Provider Information | |||||||||
| NPI: | 1730136060 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601533328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082169000 | ||||||||
| FaxNumber: | 7082169000 | ||||||||
| Practice Location | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601533328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082169000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 03/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | 036083260 | IL | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 1151181 | 05 | LA | MEDICAID | 255987100 | 05 | FL | MEDICAID | 51044493 | 01 | AL | BLUE CROSS | OTHER | 17-10433 | 01 | AL | UNITED HEALTH CARE | OTHER | 51592788 | 01 | AL | BCBS - 2451 FILLINGIM | OTHER | 00120450 | 05 | MS | MEDICAID | 000044493 | 05 | AL | MEDICAID | 020042466 | 01 | AL | RAILROAD MEDICARE PTAN | OTHER | 51593901 | 01 | AL | BCBS - 575 STANTON ROAD | OTHER |