1750569810 NPI number — JOHN C MADDEN M.D.

Table of content: JOHN C MADDEN M.D. (NPI 1750569810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750569810 NPI number — JOHN C MADDEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADDEN
Provider First Name:
JOHN
Provider Middle Name:
C
Provider Name Prefix Text:
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:
1750569810
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23340
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63156-3340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-965-5437
Provider Business Mailing Address Fax Number:
314-965-5439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9580 WATSON RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63126-1539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-965-5437
Provider Business Practice Location Address Fax Number:
314-965-5439
Provider Enumeration Date:
01/31/2008

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: 208000000X , with the licence number:  2005026245 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 342893 . This is a "GHP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 2725138 . This is a "CIGNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 9310122 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 906382 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 2868804 . This is a "UHC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 000000561731 . This is a "ANTHEM BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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