MEDICARE: MADISON STREET PROVIDER NETWORK INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist
2	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1154928331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADISON STREET PROVIDER NETWORK INC

Provider Business Mailing Address
First Line	:	PO BOX 912914
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80291-2914
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4103 BOARDWALK DR UNIT 100
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-5933
Country	:	US
Telephone Number	:	303-393-8565
Fax Number	:	303-377-2022

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GEORGE L NEAL
Credential	:
Telephone Number	:	469-214-0144

Provider Enumeration Date	:	10/01/2020
Last Update Date	:	10/01/2020

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