Provider Demographics
NPI:1366568412
Name:MADISON INTEGRATIVE MEDICINE ALLIANCE, INC
Entity type:Organization
Organization Name:MADISON INTEGRATIVE MEDICINE ALLIANCE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:OMD, MD, PHD, LAC
Authorized Official - Phone:608-238-3333
Mailing Address - Street 1:6255 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3485
Mailing Address - Country:US
Mailing Address - Phone:608-238-3333
Mailing Address - Fax:608-238-3374
Practice Address - Street 1:6255 UNIVERSITY AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-3485
Practice Address - Country:US
Practice Address - Phone:608-238-3333
Practice Address - Fax:608-238-3374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI187171100000X
WI232171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty