Healthcare Provider Details

I. General information

NPI: 1962664060
Provider Name (Legal Business Name): MADISON COMMUNITY HOSPITAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 E 12 MILE RD
WARREN MI
48092-2534
US

IV. Provider business mailing address

4050 E 12 MILE RD
WARREN MI
48092-2534
US

V. Phone/Fax

Practice location:
  • Phone: 586-578-0220
  • Fax: 586-578-0225
Mailing address:
  • Phone: 586-578-0220
  • Fax: 586-578-0225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301008844
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RYAN GUNABALAN
Title or Position: OWNER
Credential:
Phone: 248-792-1746