Healthcare Provider Details

I. General information

NPI: 1285704957
Provider Name (Legal Business Name): BRENTLY T MADARIS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4614 TRION TELOGA RD
SUMMERVILLE GA
30747-6314
US

IV. Provider business mailing address

4614 TRION TELOGA RD
SUMMERVILLE GA
30747-6314
US

V. Phone/Fax

Practice location:
  • Phone: 865-670-1003
  • Fax: 865-670-1004
Mailing address:
  • Phone: 423-364-6164
  • Fax: 224-215-3979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAPN0000006974
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN097785
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: