Provider Demographics
NPI:1770256836
Name:MADISON PHYSICIAN GROUP INC
Entity Type:Organization
Organization Name:MADISON PHYSICIAN GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-660-2665
Mailing Address - Street 1:104 W COURT AVE
Mailing Address - Street 2:
Mailing Address - City:SELMER
Mailing Address - State:TN
Mailing Address - Zip Code:38375-2102
Mailing Address - Country:US
Mailing Address - Phone:833-713-8349
Mailing Address - Fax:731-660-2121
Practice Address - Street 1:104 W COURT AVE
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-2102
Practice Address - Country:US
Practice Address - Phone:833-713-8349
Practice Address - Fax:731-660-2121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty