Provider Demographics
NPI:1063019214
Name:MADISON STREET PROVIDER NETWORK INC
Entity Type:Organization
Organization Name:MADISON STREET PROVIDER NETWORK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-214-0144
Mailing Address - Street 1:PO BOX 912914
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-2914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6881 S YOSEMITE ST
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-1406
Practice Address - Country:US
Practice Address - Phone:303-733-2020
Practice Address - Fax:303-377-2022
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MADISON STREET PROVIDER NETWORK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty