Provider Demographics
NPI:1124235452
Name:MARK MADIS,M.D. , LLC
Entity type:Organization
Organization Name:MARK MADIS,M.D. , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:MADIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-864-5033
Mailing Address - Street 1:PO BOX 1010
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:NJ
Mailing Address - Zip Code:07462-1010
Mailing Address - Country:US
Mailing Address - Phone:973-864-5033
Mailing Address - Fax:973-209-1895
Practice Address - Street 1:212 ROUTE 94
Practice Address - Street 2:SUITE 1A
Practice Address - City:VERNON
Practice Address - State:NJ
Practice Address - Zip Code:07462-3328
Practice Address - Country:US
Practice Address - Phone:973-864-5033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04014100207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C56310Medicare UPIN