Provider Demographics
NPI:1962492744
Name:MADEJ, CARRIE L (DO)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:MADEJ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 740209
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30370-4029
Mailing Address - Country:US
Mailing Address - Phone:678-814-4901
Mailing Address - Fax:678-814-4908
Practice Address - Street 1:917 JONESBORO ROAD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6031
Practice Address - Country:US
Practice Address - Phone:678-814-4901
Practice Address - Fax:678-814-4908
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA53123207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA399112982AMedicaid
GA399112982AMedicaid
GA11SCFKCMedicare ID - Type Unspecified