Basic Information
| Provider Information | |||||||||
| NPI: | 1386633477 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 250 PLEASANT STREET | ||||||||
| Address2: | CAPITAL REGION FAMILY | ||||||||
| City: | CONCORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032287200 | ||||||||
| FaxNumber: | 6032287307 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 PLEASANT STREET | ||||||||
| Address2: | CAPITAL REGION FAMILY | ||||||||
| City: | CONCORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032287200 | ||||||||
| FaxNumber: | 6032287307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 07/15/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 13596 | NH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4158828 | 01 | NH | MRP | OTHER | G35240 | 01 | NH | HARVARE PILGRIM | OTHER | 3073313 | 05 | NH | MEDICAID | 01YP12076NH01 | 01 | NH | ANTHEM | OTHER | 1018111 | 05 | VT | MEDICAID | 22-2594672 | 01 | NH | UNITED HEALTHCARE | OTHER | 22-2594672 | 01 | NH | MARTIN POINT | OTHER | 4906674 | 01 | NH | CIGNA | OTHER | 30206977 | 05 | NH | MEDICAID |