Basic Information
| Provider Information | |||||||||
| NPI: | 1851014203 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADISON | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 990 W FOREST AVE APT 1 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494412245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313436938 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1115 BALL AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495055904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164566571 | ||||||||
| FaxNumber: | 6162350979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2022 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.