Provider Demographics
NPI:1891960092
Name:ANDREW J. MADAK, D.O., P.C.
Entity Type:Organization
Organization Name:ANDREW J. MADAK, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MADAK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-601-5780
Mailing Address - Street 1:455 S LIVERNOIS RD
Mailing Address - Street 2:C-22
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2578
Mailing Address - Country:US
Mailing Address - Phone:248-601-5780
Mailing Address - Fax:248-605-8786
Practice Address - Street 1:455 S LIVERNOIS RD
Practice Address - Street 2:C-22
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-2578
Practice Address - Country:US
Practice Address - Phone:248-601-5780
Practice Address - Fax:248-605-8786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI510102535261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI56304394OtherBCBSM
MI0M85940Medicare PIN
MIG59289Medicare UPIN