Provider Demographics
NPI:1992747570
Name:MADISON CO MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:MADISON CO MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:DM, RN, RODP
Authorized Official - Phone:208-359-6900
Mailing Address - Street 1:450 E. MAIN
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440
Mailing Address - Country:US
Mailing Address - Phone:208-359-6900
Mailing Address - Fax:208-359-9879
Practice Address - Street 1:450 E. MAIN
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-359-6900
Practice Address - Fax:208-359-9879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID40282N00000X
282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00109OtherBLUE CROSS OF IDAHO
ID002855700Medicaid
ID2855700Medicaid
ID000010006291OtherREGENCE BLUE SHIELD OF ID
ID130025Medicare ID - Type Unspecified