1821031865 NPI number — DR. MICHAEL MADDOX M.D.

Table of content: DR. MICHAEL MADDOX M.D. (NPI 1821031865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821031865 NPI number — DR. MICHAEL MADDOX M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADDOX
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1821031865
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8910 PURDUE RD
Provider Second Line Business Mailing Address:
STE.500
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46268-3161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6820 PARKDALE PL
Provider Second Line Business Practice Location Address:
STE. 100
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46254-6601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-297-7773
Provider Business Practice Location Address Fax Number:
317-297-3619
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  01039540 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100118880 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com