Provider Demographics
NPI:1659838456
Name:MADISON MEDNORTH PRIMARY CARE
Entity Type:Organization
Organization Name:MADISON MEDNORTH PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROMUALDO ENRIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-278-9731
Mailing Address - Street 1:17449 CARILLON DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35611-0617
Mailing Address - Country:US
Mailing Address - Phone:256-278-9731
Mailing Address - Fax:
Practice Address - Street 1:101 WESTOVER CIR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-4909
Practice Address - Country:US
Practice Address - Phone:256-278-9731
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty