Provider Demographics
NPI:1639647993
Name:VANSAVAGE MABEN, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:VANSAVAGE MABEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 NETWORK STA
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-3851
Mailing Address - Country:US
Mailing Address - Phone:757-892-5300
Mailing Address - Fax:757-892-5303
Practice Address - Street 1:433 NETWORK STA
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320
Practice Address - Country:US
Practice Address - Phone:757-892-5300
Practice Address - Fax:757-892-5303
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACO005977222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009190414Medicaid
VA09190414Medicaid