Basic Information
| Provider Information | |||||||||
| NPI: | 1376691154 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MADISON CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 E MADISON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466172322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742340061 | ||||||||
| FaxNumber: | 5742831209 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 E MADISON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466172322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742340061 | ||||||||
| FaxNumber: | 5742831209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 04/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | CLANTON | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5742831107 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MADISON CENTER, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 406-1-PIP | IN | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 283Q00000X | 406-1-PIP | IN | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 100276950 | 05 | IN | MEDICAID |