Basic Information
Provider Information | |||||||||
NPI: | 1851469142 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MADISON BEHAVIORAL DIAGNOSTIC AND TREATMENT SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 383 | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | AL | ||||||||
PostalCode: | 357580383 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2568958148 | ||||||||
FaxNumber: | 2564898148 | ||||||||
Practice Location | |||||||||
Address1: | 1643 SLAUGHTER RD | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | AL | ||||||||
PostalCode: | 357588692 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2568958148 | ||||||||
FaxNumber: | 2564898148 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2006 | ||||||||
LastUpdateDate: | 02/01/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ADAMS | ||||||||
AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT OWNER | ||||||||
AuthorizedOfficialTelephone: | 2568958148 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 22646 | AL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.