Basic Information
| Provider Information | |||||||||
| NPI: | 1891870218 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOADA | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776879 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 3118 E 10TH ST STE B | ||||||||
| Address2: | |||||||||
| City: | JEFFERSONVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471305904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122854585 | ||||||||
| FaxNumber: | 8122842798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 01050219A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 32419 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | IN4465001 | 01 | IN | MEDICARE | OTHER | 200209820 | 05 | IN | MEDICAID | 64324197 | 05 | KY | MEDICAID |