Healthcare Provider Details

I. General information

NPI: 1710636139
Provider Name (Legal Business Name): SYDNEY MADISON STREET PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44405 WOODARD AVE SUITE 202
PONTIAC MI
48341
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DRIVE SUITE J2000
ANN ARBOR MI
48105
US

V. Phone/Fax

Practice location:
  • Phone: 810-342-3801
  • Fax: 810-342-3856
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011053
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: