Provider Demographics
NPI:1366772725
Name:MADISON SPECIALTY CENTER, LLC
Entity type:Organization
Organization Name:MADISON SPECIALTY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:NORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:812-265-5800
Mailing Address - Street 1:PO BOX 816
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-0816
Mailing Address - Country:US
Mailing Address - Phone:812-265-5800
Mailing Address - Fax:812-265-5864
Practice Address - Street 1:2580 MICHIGAN RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-2491
Practice Address - Country:US
Practice Address - Phone:812-265-5800
Practice Address - Fax:812-265-5864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-07
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028535A207K00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100204700Medicaid
15D1076663OtherCLIA
IN1457341281OtherNPI
IN100204700Medicaid
IN412800AMedicare PIN
IN1457341281OtherNPI