MEDICARE: DR. OLIVIA PENN MADAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	60988	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1659549608	OTHER	TN	PRACTICE NPI

General Provider Information

NPI Number	:	1861805921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OLIVIA PENN MADAN M.D.

Provider Business Mailing Address
First Line	:	905 S HAWTHORNE RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-4416
Country	:	US
Telephone Number	:	864-650-6228
Fax Number	:

Provider Business Practice Location Address
First Line	:	1914 CHARLOTTE AVE STE 101
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37203-2231
Country	:	US
Telephone Number	:	615-327-0303
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2014
Last Update Date	:	02/16/2021

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