Provider Demographics
NPI:1225711872
Name:FOGLE, MADISON (RD)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:FOGLE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2052 STONE BROOK DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5364
Mailing Address - Country:US
Mailing Address - Phone:205-447-6326
Mailing Address - Fax:
Practice Address - Street 1:7191 CAHABA VALLEY RD
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35242-6443
Practice Address - Country:US
Practice Address - Phone:205-408-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3392133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered