Healthcare Provider Details

I. General information

NPI: 1861502635
Provider Name (Legal Business Name): MADISON MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W. MAPLE
FAIRFAX OK
74637-1533
US

IV. Provider business mailing address

P.O. BOX 187
FAIRFAX OK
74637-0187
US

V. Phone/Fax

Practice location:
  • Phone: 918-642-5310
  • Fax: 918-642-3690
Mailing address:
  • Phone: 918-642-5310
  • Fax: 918-642-3690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM LANCE MADISON
Title or Position: PRESIDENT
Credential: RRT
Phone: 918-642-5310