MEDICARE: THERESA L MADISON

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	164W00000X	Licensed Practical Nurse	33521-031	WI

General Provider Information

NPI Number	:	1740423029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA L MADISON

Provider Business Mailing Address
First Line	:	3927 N 37TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2510
Country	:	US
Telephone Number	:	414-875-8042
Fax Number	:

Provider Business Practice Location Address
First Line	:	3927 N 37TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2510
Country	:	US
Telephone Number	:	414-875-8042
Fax Number	:

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

Provider Enumeration Date	:	04/15/2009
Last Update Date	:	04/15/2009

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