Provider Demographics
NPI:1114099439
Name:MADDEN MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:MADDEN MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BENITA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBLEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-267-4562
Mailing Address - Street 1:PO BOX 435
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MS
Mailing Address - Zip Code:39051-0435
Mailing Address - Country:US
Mailing Address - Phone:601-267-4562
Mailing Address - Fax:601-267-4589
Practice Address - Street 1:1071 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051-3601
Practice Address - Country:US
Practice Address - Phone:601-267-4562
Practice Address - Fax:601-267-4589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014124Medicaid
MSC03157Medicare PIN