Provider Demographics
NPI:1043774219
Name:MADDOX, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MADDOX
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 1:119 MILBOB DR
Mailing Address - Street 2:
Mailing Address - City:WARMINSTER
Mailing Address - State:PA
Mailing Address - Zip Code:18974-1668
Mailing Address - Country:US
Mailing Address - Phone:215-696-0888
Mailing Address - Fax:
Practice Address - Street 1:8201 HENRY AVE APT K1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2220
Practice Address - Country:US
Practice Address - Phone:215-696-0888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAXOF823636392OtherBLUE CROSS BLUE
PAXOF823636392OtherBLUE CROSS BLUE SHIELD