Provider Demographics
NPI:1457753972
Name:MADU MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:MADU MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NDIDI
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:MADU
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:317-946-0591
Mailing Address - Street 1:PO BOX 83042
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-8014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1815 HIGHWAY 138 SE STE 800
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2098
Practice Address - Country:US
Practice Address - Phone:770-929-0404
Practice Address - Fax:770-929-0540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65703261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care