Healthcare Provider Details

I. General information

NPI: 1295958155
Provider Name (Legal Business Name): MADISON EAST INTERNAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 E MADISON ST
HOUSTON MS
38851-2417
US

IV. Provider business mailing address

PO BOX 648
HOUSTON MS
38851-0648
US

V. Phone/Fax

Practice location:
  • Phone: 662-448-6213
  • Fax: 662-448-6215
Mailing address:
  • Phone: 662-448-6213
  • Fax: 662-448-6215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: NOEL VILLAROSA GARCIA
Title or Position: PHYSICIAN
Credential: MD
Phone: 662-448-6213