Provider Demographics
NPI:1588725535
Name:INTERIM HEALTHCARE OF MADISON, INC
Entity type:Organization
Organization Name:INTERIM HEALTHCARE OF MADISON, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:UTTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MS
Authorized Official - Phone:608-238-0268
Mailing Address - Street 1:702 N BLACKHAWK AVE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3357
Mailing Address - Country:US
Mailing Address - Phone:608-238-0268
Mailing Address - Fax:608-238-7308
Practice Address - Street 1:702 N BLACKHAWK AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3357
Practice Address - Country:US
Practice Address - Phone:608-238-0268
Practice Address - Fax:608-238-7308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI206251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43103700Medicaid
WI206OtherWI HHA LICENSE NUMBER