Provider Demographics
NPI:1043787294
Name:MADISON ORTHOPEDIC REHAB
Entity Type:Organization
Organization Name:MADISON ORTHOPEDIC REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:OVERPECK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:812-265-8226
Mailing Address - Street 1:219 CLIFTY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-1603
Mailing Address - Country:US
Mailing Address - Phone:812-265-8228
Mailing Address - Fax:812-265-8227
Practice Address - Street 1:219 CLIFTY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-1603
Practice Address - Country:US
Practice Address - Phone:812-265-8228
Practice Address - Fax:812-265-8227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-25
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300008207Medicaid