Provider Demographics
NPI:1225169626
Name:MADONNA RINGSWALD DO PSC
Entity Type:Organization
Organization Name:MADONNA RINGSWALD DO PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MADONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RINGSWALD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:502-222-1545
Mailing Address - Street 1:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-0065
Mailing Address - Country:US
Mailing Address - Phone:502-222-1545
Mailing Address - Fax:502-222-1679
Practice Address - Street 1:1031 NEW MOODY LN
Practice Address - Street 2:SUITE 301
Practice Address - City:LAGRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9151
Practice Address - Country:US
Practice Address - Phone:502-222-1545
Practice Address - Fax:502-222-1679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02114207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65919623Medicaid
KY2434204000OtherPASSPORT ADVANTAGE
KY1055793OtherPASSPORT
KY1055793OtherPASSPORT
KY2434204000OtherPASSPORT ADVANTAGE