Provider Demographics
NPI:1073732178
Name:MADISON MEDICAL CENTER PC
Entity Type:Organization
Organization Name:MADISON MEDICAL CENTER PC
Other - Org Name:MADISON HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNABALAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-583-8922
Mailing Address - Street 1:30781 STEPHENSON HWY
Mailing Address - Street 2:
Mailing Address - City:MADISON HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1618
Mailing Address - Country:US
Mailing Address - Phone:248-583-8922
Mailing Address - Fax:248-583-8969
Practice Address - Street 1:363 W BIG BEAVER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-5220
Practice Address - Country:US
Practice Address - Phone:248-619-9471
Practice Address - Fax:248-619-9774
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MADISON MEDICAL CENTER PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-25
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P44550Medicare PIN