MEDICARE: MICHAEL CAMERON MADDOX RN

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	163W00000X	Registered Nurse	95198315	CA

General Provider Information

NPI Number	:	1700497443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL CAMERON MADDOX RN

Provider Business Mailing Address
First Line	:	1013 N LACROSSE ST APT A10
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-6959
Country	:	US
Telephone Number	:	925-565-3169
Fax Number	:

Provider Business Practice Location Address
First Line	:	1013 N LACROSSE ST APT A10
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-6959
Country	:	US
Telephone Number	:	925-565-3169
Fax Number	:

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

Provider Enumeration Date	:	08/16/2020
Last Update Date	:	05/05/2025

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