Provider Demographics
NPI:1295958155
Name:MADISON EAST INTERNAL MEDICINE LLC
Entity type:Organization
Organization Name:MADISON EAST INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:VILLAROSA
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-448-6213
Mailing Address - Street 1:PO BOX 648
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851-0648
Mailing Address - Country:US
Mailing Address - Phone:662-448-6213
Mailing Address - Fax:662-448-6215
Practice Address - Street 1:1002 E MADISON ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-2417
Practice Address - Country:US
Practice Address - Phone:662-448-6213
Practice Address - Fax:662-448-6215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126007Medicaid
MSG20415Medicare UPIN
MS00126007Medicaid