Provider Demographics
NPI:1114768868
Name:EDGECOMB, MADISON RAE (MS LAT ATC)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:RAE
Last Name:EDGECOMB
Suffix:
Gender:F
Credentials:MS LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 FARRINGTON ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-5023
Mailing Address - Country:US
Mailing Address - Phone:812-344-5030
Mailing Address - Fax:
Practice Address - Street 1:7356 E COUNTY ROAD 50 S
Practice Address - Street 2:
Practice Address - City:DUGGER
Practice Address - State:IN
Practice Address - Zip Code:47848-8101
Practice Address - Country:US
Practice Address - Phone:812-648-2729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36003901A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer