Provider Demographics
NPI:1215963830
Name:MADDEN, RUPERT GARY (MD)
Entity type:Individual
Prefix:DR
First Name:RUPERT
Middle Name:GARY
Last Name:MADDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1909
Mailing Address - Country:US
Mailing Address - Phone:571-787-6440
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:3510 N CAUSEWAY BLVD
Practice Address - Street 2:SUITE 404
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-3531
Practice Address - Country:US
Practice Address - Phone:504-779-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015583174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA53591Medicaid
1337145Medicare ID - Type Unspecified
B89718Medicare UPIN