Provider Demographics
NPI:1861502635
Name:MADISON MEDICAL LLC
Entity Type:Organization
Organization Name:MADISON MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:LANCE
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:918-642-5310
Mailing Address - Street 1:P.O. BOX 187
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:OK
Mailing Address - Zip Code:74637-0187
Mailing Address - Country:US
Mailing Address - Phone:918-642-5310
Mailing Address - Fax:918-642-3690
Practice Address - Street 1:115 W. MAPLE
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:OK
Practice Address - Zip Code:74637-1533
Practice Address - Country:US
Practice Address - Phone:918-642-5310
Practice Address - Fax:918-642-3690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100811270AMedicaid
5362290001Medicare UPIN