Provider Demographics
NPI:1366436669
Name:MADISON CLINIC CORP DBA JACKSON PEDIATRIC CENTER
Entity type:Organization
Organization Name:MADISON CLINIC CORP DBA JACKSON PEDIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-664-9928
Mailing Address - Street 1:37 SANDSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2073
Mailing Address - Country:US
Mailing Address - Phone:731-664-9928
Mailing Address - Fax:731-664-9749
Practice Address - Street 1:37 SANDSTONE CIR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2073
Practice Address - Country:US
Practice Address - Phone:731-664-9928
Practice Address - Fax:731-664-9749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38747208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH00089Medicare UPIN