Healthcare Provider Details

I. General information

NPI: 1730109687
Provider Name (Legal Business Name): MARK S MADIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HATFIELD LN
GOSHEN NY
10924-6766
US

IV. Provider business mailing address

20 GRAND ST FL 3
WARWICK NY
10990-1035
US

V. Phone/Fax

Practice location:
  • Phone: 845-291-7400
  • Fax: 845-291-7049
Mailing address:
  • Phone: 845-294-8888
  • Fax: 845-987-5979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number149680
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: