1225169626 NPI number — MADONNA RINGSWALD DO PSC

Table of content: (NPI 1225169626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225169626 NPI number — MADONNA RINGSWALD DO PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MADONNA RINGSWALD DO PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225169626
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 65
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGRANGE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40031-0065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-222-1545
Provider Business Mailing Address Fax Number:
502-222-1679

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1031 NEW MOODY LN
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40031-9151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-222-1545
Provider Business Practice Location Address Fax Number:
502-222-1679
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RINGSWALD
Authorized Official First Name:
MADONNA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
502-222-1545

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  02114 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 65919623 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2434204000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1055793 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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