Provider Demographics
NPI:1811789365
Name:ALBERT, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:ALBERT
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 RAVEN FALLS LN
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-8100
Mailing Address - Country:US
Mailing Address - Phone:864-608-6181
Mailing Address - Fax:
Practice Address - Street 1:1626 HIGHWAY 30 E
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-2319
Practice Address - Country:US
Practice Address - Phone:662-371-1326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-20
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00899363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant