Provider Demographics
NPI:1093866147
Name:MADISON, MICHAEL EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:MADISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2094 E STATE ST STE B
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-4409
Mailing Address - Country:US
Mailing Address - Phone:330-337-8709
Mailing Address - Fax:
Practice Address - Street 1:2094 E STATE ST STE B
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-4409
Practice Address - Country:US
Practice Address - Phone:330-337-8709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-9908-M207QA0401X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2116338Medicaid
OH0876421Medicare ID - Type UnspecifiedMEDICARE
OH2116338Medicaid