Provider Demographics
NPI:1013408962
Name:MADONNA, JAMES (PT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:MADONNA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80650 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:BRUCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48065-1333
Mailing Address - Country:US
Mailing Address - Phone:810-798-6470
Mailing Address - Fax:810-798-6476
Practice Address - Street 1:80650 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:BRUCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48065-1333
Practice Address - Country:US
Practice Address - Phone:810-798-6470
Practice Address - Fax:810-798-6476
Is Sole Proprietor?:No
Enumeration Date:2018-05-27
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006190225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist