Basic Information
Provider Information | |||||||||
NPI: | 1942237326 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MADDUX | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | T | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 12 | ||||||||
Address2: |   | ||||||||
City: | LIBERTY LAKE | ||||||||
State: | WA | ||||||||
PostalCode: | 990190012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4063271918 | ||||||||
FaxNumber: | 4063292937 | ||||||||
Practice Location | |||||||||
Address1: | 500 W BROADWAY ST | ||||||||
Address2: | SUITE 320 | ||||||||
City: | MISSOULA | ||||||||
State: | MT | ||||||||
PostalCode: | 598024003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4063295615 | ||||||||
FaxNumber: | 4063295606 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2006 | ||||||||
LastUpdateDate: | 03/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 10525 | MT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 0147407 | 05 | MT |   | MEDICAID |