=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215687058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN E MADDOX NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2022
-----------------------------------------------------
Last Update Date | 11/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 445 CLIFTY DR
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47250-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-273-5372
-----------------------------------------------------
Fax | 812-273-5741
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4715 N 350 W
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47250-8043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-717-1790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 71012403A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | CS0365835
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------