Provider Demographics
NPI:1801117007
Name:SHASHI MADAN MD PC
Entity type:Organization
Organization Name:SHASHI MADAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MASNAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-775-7675
Mailing Address - Street 1:135 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1942
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 N OAK ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1942
Practice Address - Country:US
Practice Address - Phone:770-775-7675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037279251B00000X, 251E00000X, 302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000568554BMedicaid
GA11BDHVNMedicare PIN