Basic Information
Provider Information | |||||||||
NPI: | 1073565131 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MADISON CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 403 E MADISON ST | ||||||||
Address2: |   | ||||||||
City: | SOUTH BEND | ||||||||
State: | IN | ||||||||
PostalCode: | 466172322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5742831107 | ||||||||
FaxNumber: | 5742831131 | ||||||||
Practice Location | |||||||||
Address1: | 403 E MADISON ST | ||||||||
Address2: |   | ||||||||
City: | SOUTH BEND | ||||||||
State: | IN | ||||||||
PostalCode: | 466172322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5742831107 | ||||||||
FaxNumber: | 5742831131 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POOLE | ||||||||
AuthorizedOfficialFirstName: | ANDREW | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 5742831254 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X |   | IN | Y |   | Hospitals | Psychiatric Hospital |   |
No ID Information.