Healthcare Provider Details

I. General information

NPI: 1437102415
Provider Name (Legal Business Name): MADISON CLINIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 HOSPITAL BLVD
JACKSON TN
38305-2080
US

IV. Provider business mailing address

7100 COMMERCE WAY SUITE 180
BRENTWOOD TN
37027-2829
US

V. Phone/Fax

Practice location:
  • Phone: 731-660-3476
  • Fax:
Mailing address:
  • Phone: 615-465-7626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE BREWER
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT
Credential:
Phone: 615-465-7626