Healthcare Provider Details

I. General information

NPI: 1285486514
Provider Name (Legal Business Name): MADISON MAIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 05/05/2024
Certification Date: 05/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE
ATLANTA GA
30322-1059
US

IV. Provider business mailing address

4501 NE 55TH ST
SEATTLE WA
98105-2937
US

V. Phone/Fax

Practice location:
  • Phone: 404-727-5658
  • Fax:
Mailing address:
  • Phone: 206-307-7582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number16018
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: