Healthcare Provider Details

I. General information

NPI: 1528471463
Provider Name (Legal Business Name): BIRRILLA MADDOX D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 STATE ST
NEW ALBANY IN
47150-4990
US

IV. Provider business mailing address

350 HOSPITAL WAY SUITE 101
SOMERSET KY
42503-2872
US

V. Phone/Fax

Practice location:
  • Phone: 812-944-7701
  • Fax: 812-981-6505
Mailing address:
  • Phone: 606-451-5092
  • 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 State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number02005072A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04002
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: