Provider Demographics
NPI:1063463545
Name:MADISON MEDICAL P.C
Entity Type:Organization
Organization Name:MADISON MEDICAL P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TUSHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIPATHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-369-3379
Mailing Address - Street 1:24661 COOLIDGE HWY
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1449
Mailing Address - Country:US
Mailing Address - Phone:313-369-3379
Mailing Address - Fax:313-893-6346
Practice Address - Street 1:3120 CARPENTER ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-9802
Practice Address - Country:US
Practice Address - Phone:313-369-3379
Practice Address - Fax:313-893-6346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX IDENTIFICATION
MI0P20380Medicare PIN