Provider Demographics
NPI:1447500418
Name:LK MADISON MD LLC
Entity type:Organization
Organization Name:LK MADISON MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:641-872-2260
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:417 S EAST ST
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IA
Practice Address - Zip Code:50060-1860
Practice Address - Country:US
Practice Address - Phone:641-872-2260
Practice Address - Fax:641-872-3656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA334362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIN PROCESSMedicaid
IAIN PROCESSMedicaid