Basic Information
| Provider Information | |||||||||
| NPI: | 1477605335 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MADISON HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6185 PASEO DEL NORTE, STE 150 | ||||||||
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| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552592288 | ||||||||
| FaxNumber: | 7609188712 | ||||||||
| Practice Location | |||||||||
| Address1: | 5109 WORLD DAIRY DR. | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082420220 | ||||||||
| FaxNumber: | 6082421166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 11/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | PROCOPIO | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT EAST DIV. | ||||||||
| AuthorizedOfficialTelephone: | 5705382567 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 42225600 | 05 | WI | MEDICAID |