Healthcare Provider Details

I. General information

NPI: 1124750690
Provider Name (Legal Business Name): MADELEINE ANN PRICE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2022
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6262 VETERANS PKWY
COLUMBUS GA
31909-3540
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 706-324-6661
  • Fax:
Mailing address:
  • Phone:
  • Fax: 706-494-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number11020
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: