MEDICARE: MADISON OB/GYN ASSOCIATES LLC

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	174400000X	Specialist
2	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1699068775
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADISON OB/GYN ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	115 FOUNTAINS BLVD
Second Line	:	SUITE A
City	:	MADISON
State	:	MS
Zip	:	39110-6344
Country	:	US
Telephone Number	:	601-853-0100
Fax Number	:	601-853-3999

Provider Business Practice Location Address
First Line	:	115 FOUNTAINS BLVD
Second Line	:	SUITE A
City	:	MADISON
State	:	MS
Zip	:	39110-6344
Country	:	US
Telephone Number	:	601-853-0100
Fax Number	:	601-853-3999

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. LESLIE F MASON
Credential	:	MD
Telephone Number	:	601-853-0100

Provider Enumeration Date	:	05/23/2011
Last Update Date	:	12/13/2022

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