Basic Information
| Provider Information | |||||||||
| NPI: | 1730109687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADIS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GRAND ST | ||||||||
| Address2: | FL 3 | ||||||||
| City: | WARWICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109901035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452948888 | ||||||||
| FaxNumber: | 8459875979 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HATFIELD LN | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109246766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452917400 | ||||||||
| FaxNumber: | 8452917049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 149680 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00782605 | 05 | NY | MEDICAID |