Provider Demographics
NPI:1306509336
Name:ZIMMER, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:ZIMMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 LANDINGS CT
Mailing Address - Street 2:
Mailing Address - City:CHURCHVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21028-1234
Mailing Address - Country:US
Mailing Address - Phone:443-910-0505
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-235-3036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-17
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD004294231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAUD004294OtherPROFESSIONAL LICENSE