Provider Demographics
NPI:1184814980
Name:J. BRAD MADDEN, MD FAMILY MEDICINE
Entity Type:Organization
Organization Name:J. BRAD MADDEN, MD FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SINCLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-376-1259
Mailing Address - Street 1:98 BURNHAM RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2759
Mailing Address - Country:US
Mailing Address - Phone:601-933-1676
Mailing Address - Fax:601-933-9781
Practice Address - Street 1:98 BURNHAM RD
Practice Address - Street 2:SUITE B
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2759
Practice Address - Country:US
Practice Address - Phone:601-933-1676
Practice Address - Fax:601-933-9781
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVER OAKS MANAGEMENT COMPANY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-27
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02454Medicare PIN