MEDICARE: MADISON AYERS HUMPHREYS CAA

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	390200000X	Student in an Organized Health Care Education/Training Program
2	367H00000X	Anesthesiologist Assistant	12910	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12910	OTHER	GA	GEORGIA MEDICAL BOARD

General Provider Information

NPI Number	:	1588484141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON AYERS HUMPHREYS CAA

Provider Business Mailing Address
First Line	:	1836 DELPHINE DR
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30032-3927
Country	:	US
Telephone Number	:	478-607-1114
Fax Number	:

Provider Business Practice Location Address
First Line	:	364 CLIFTON RD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30322-3927
Country	:	US
Telephone Number	:	404-778-3900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2024
Last Update Date	:	02/27/2025

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