Provider Demographics
NPI:1396706131
Name:MENON, MADHU (MD)
Entity type:Individual
Prefix:DR
First Name:MADHU
Middle Name:
Last Name:MENON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TEKKEPATTE
Other - Middle Name:
Other - Last Name:MADHUSUDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 BRETZ CT STE 100
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17074-8615
Mailing Address - Country:US
Mailing Address - Phone:717-567-3174
Mailing Address - Fax:717-703-0018
Practice Address - Street 1:300 BRETZ CT STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:PA
Practice Address - Zip Code:17074-8615
Practice Address - Country:US
Practice Address - Phone:717-567-3174
Practice Address - Fax:717-703-0018
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD061440L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001692743Medicaid
PA1136775OtherFIRST HEALTH
PAP967510OtherGATEWAY
PA0228002OtherKEYSTONE
PA080137007OtherRAIL ROAD MEDICARE
PA860303OtherAETNA
PAME967510OtherHIGHMARK BLUE SHIELD
PA003282Medicare PIN
PA860303OtherAETNA