1891898789 NPI number — MADISON COUNTY MEDICAL GROUP INC

Table of content: (NPI 1891898789)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891898789 NPI number — MADISON COUNTY MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MADISON COUNTY MEDICAL GROUP INC
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:
1891898789
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 860
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTSVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72740-0860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-738-1700
Provider Business Mailing Address Fax Number:
479-738-5510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 PHILLIPS PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTSVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-738-1700
Provider Business Practice Location Address Fax Number:
479-738-5510
Provider Enumeration Date:
09/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HATFIELD
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CLINIC ADMINSTRATOR
Authorized Official Telephone Number:
479-738-1700

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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